This chapter describes an integration approach to enhancing the environmental medicine content of the medical school curriculum. However, at the outset, it is important to emphasize the critical need for an interested and willing faculty with competence in environmental medicine. Without this competence and commitment, the most creative and relevant curriculum will have no more life than the paper it is printed on. With the paucity of environmental medicine expertise in medical schools (Institute of Medicine, 1988; 1993a), any implementation strategy must address the need to expand and enhance the cadre of medical school faculty with this expertise. Without at least one champion to advance the cause of environmental medicine in curriculum committees and departments, even modest efforts to create an environmental focus in existing courses and clerkships are unlikely to succeed. We address this fundamental necessity in greater detail later in this chapter.
To begin the task of enhancing the content of environmental medicine in the curriculum of any particular medical school, it is advisable and reasonable to first inventory and assess what is currently in place. Once it has been established that a content area, such as environmental medicine, is underemphasized, then a basis for action is created. Building a consensus on a current problem or deficiency, however, is often easier than gaining support for a specific solution. Proposals for specific solutions may provoke claims that such solutions have been tried and failed. While such claims may be true, individuals and communities continue to be concerned with environmental issues
and have a growing understanding and appreciation of the influence of the environment on health and the need for action.
Developing an inventory also provides a critical opportunity to identify and assess faculty interest and expertise in environmental health. The importance of personal contacts in creating learning opportunities cannot be over-stated. Allies and interest may be found in unexpected places—from the biochemist by profession who wants to build more clinical relevance into his/her course to the busy family practitioner who is stymied by patients with symptoms related to indoor air quality.
Once an inventory establishes a need within a given institution, sources of support must be identified. Influential support, such as from a departmental chair, a prominent investigator, a favorite instructor, or a highly regarded clinician, can be very helpful. Members of the student body should not be overlooked; they are often powerful advocates for environmental issues and for understanding their effects on health. It is also important to know the location and basis of opposition, because such understanding can expedite discussions and facilitate resolutions.
In order for tomorrow’s physicians to have the knowledge, skills, and attitudes needed to practice medicine in a society in which the environment is of increasing concern, environmental medicine must be integrated into medical school education. Toward this end, the committee recommends that all graduating medical students master the six competencies (described in Chapter 2 of this report) that encompass the requisite core knowledge and skills. Where and when these competencies will best be learned depends on the structure and format of each individual school’s specific curriculum. (As has been said numerous times by committee member Brownie Anderson, “If you’ve seen one medical school, you’ve seen one medical school.”) Regardless of the specific structure and format, however, the fundamental content of the medical curriculum is relatively consistent and amenable to the integration or enhancement of environmental medicine concepts and information.
Rather than defining and carving out new blocks or courses in an already crowded curriculum, the committee favors an integrative approach to enhancing the environmental and occupational health content in undergraduate medical education. This is not only the most expeditious way to achieve the competency objectives, but it also seems to be the most appropriate given the pervasive nature of the effects of the environment on health. Integration also highlights the relevance of environmental and occupational medicine to basic science and clinical studies, and provides a vehicle for enhancing faculty awareness of the issues. Moreover, instructors should be able to integrate environmental medicine into existing disciplines and medical school courses and clerkships fairly easily.
To show how the six competencies can be integrated into existing programs, this chapter discusses each one in terms of likely access points in the curriculum and possible teaching strategies. The competencies can be grouped into those that are more knowledge oriented (competencies 1–3) and those that focus more on skills (competencies 3–6; competency 3 overlaps both groups)—similar to the basic science/preclinical and
clinical years found in a traditional medical curriculum. The chapter concludes with some institutional strategies and suggestions for enhancing faculty awareness of the growing need to develop educational opportunities for student achievement of these competencies.
The chapter is supplemented by Appendix B, which provides suggestions for integrating environmental medicine into specific courses and clerkships, and Appendix C, which contains numerous case examples. In order to facilitate the identification and use of these cases for different teaching purposes, they are indexed (in the front of Appendix C) according to chemical agent, specific courses and clerkships, sentinel pathophysiological conditions, and clinical signs, symptoms, and presenting complaints. The actual content or teaching method used for presenting this information and achieving the related learning objectives will and should vary according to faculty interest and expertise, institutional resources and constraints, and the ongoing level of curriculum change.
CURRICULUM ACCESS POINTS AND TEACHING STRATEGIES
We consider competencies 1 and 2 together here because they are primarily knowledge-based. The courses that would most appropriately begin to introduce the environmental and occupational material needed to achieve these competencies can usually be found in the basic science area of the medical curriculum; however, the application of this knowledge must be continually reinforced during the clinical years.
Competencies 1 and 2
Competency 1. Graduating medical students should understand the influence of the environment and environmental agents on human health based on knowledge of relevant epidemiologic, toxicologic, and exposure factors.
Competency 2. Graduating medical students should be able to recognize the signs, symptoms, diseases, and sources of exposure relating to common environmental agents and conditions.
Basic Science Courses
In most medical schools, the first two years are organized into either basic science or multidisciplinary courses that are organ-based in their focus. In either context, it is relatively easy to teach environmental medicine content without requiring additional time
in the curriculum and without much more effort. For example, a basic science faculty member teaching about oxygen transport could illustrate the principles of oxygen-hemoglobin binding by comparing the mechanisms of the binding capacity of oxygen and carbon monoxide; he/she could make the presentation or discussion clinically relevant by using, as an example, a case of a family that sustained carbon monoxide poisoning from using a portable propane heater in their inadequately ventilated home (see case study 7 in Appendix C). The spectrum of morbidity among family members could be explained
Carbon monoxide is the leading cause of poison-induced deaths in the United States (Centers for Disease Control, 1982).
by referring to interactions with other risk factors, such as smoking, both active and passive, individual activity levels, and varying ventilation levels in the home. In the process, the instructor would be illustrating both the toxicologic concept that the risk level depends on the degree of exposure and the biochemical and physiological concept that oxygen is displaced from hemoglobin by a more avid binding agent. The differing fetal and maternal kinetics of carbon monoxide could be highlighted in this case, as could the pharmacologic principles of oxygen therapy and its hazards, and the neurotoxic effects of prolonged hypoxia.
The appendixes contain numerous other examples for incorporating environmental (including occupational) content into basic science teaching. The underlying principle guiding the use of such examples in the basic science curriculum is the need for a greater emphasis on clinically relevant examples. In those schools with a problem-based learning track, it is somewhat easier to incorporate environmental and occupational issues into the curriculum. Most cases can be written to include information on environmental and occupational risk factors that are either directly relevant to the learning issues of the case or are incidentally related to them without necessarily affecting the case.
Introduction to Clinical Medicine Courses
Some courses naturally lend themselves to teaching important concepts in environmental and occupational medicine. For example, “Introduction to Clinical Medicine” courses provide specific opportunities for introducing information on disease-exposure relationships and could easily emphasize environmental and occupational exposures. A discussion of the work-up and management of a patient with suspected
interstitial lung disease, for example, which is fairly generic in its approach, could involve a patient with hypersensitivity pneumonitis secondary to exposure to pigeon antigen. Although the clinical work-up is initially similar for all patients with suspected interstitial lung disease, the specific work-up and diagnosis would clearly be dependent on an accurate environmental history and an understanding of the frequently misunder
Exposure to allergenic bioaerosols in residential or commercial heating, ventilation, and air-conditioning systems can cause hypersensitivity pneumonitis (Institute of Medicine, 1993b).
stood pathophysiology of hypersensitivity pneumonitis. It would then be important to compare distinguishing aspects of this condition with other interstitial diseases such as sarcoidosis, asbestosis, and idiopathic pulmonary fibrosis. In addition, a discussion of environmentally focused preventive measures can also be introduced as a corollary to medically oriented treatments such as oxygen and steroids.
Competency 3. Graduating medical students should be able to elicit an appropriately detailed environmental exposure history, including a work history, from all patients.
Introduction to Clinical Medicine/Medical Interviewing and Problem-Solving Courses
Introduction to clinical medicine/medical interviewing and problem-solving courses are the most logical place for teaching the skill of environmental and occupational history-taking. Environmental and occupational exposures can be considered important risk factors in what is often called the “social” history, which generally elicits information about a patient’s life-style risks. Several strategies can be used to include and enhance students’ environmental and occupational history-taking skills. For example:
Patient Write-Ups. Detailed environmental and occupational history and exposure information can be a required component of the patient write-ups that students are typically asked to submit.
Role-Playing. It may be interesting and useful to have students take histories from each other. Environmental and occupational exposure issues will likely surface as a result because some students will have encountered potentially hazardous environmental exposures through their hobbies, home and community environments, previous employment, or medical training (e.g., formaldehyde used to preserve specimens in the anatomy labs).
Standardized Patients. Patient-instructors are used increasingly to train students in the skills of interviewing, communication, and physical examination. Environmental and occupational elements can be easily added to these patients’ scripts or scenarios. Indeed, the use of standardized patients to teach and evaluate history-taking skills should routinely require the elicitation of relevant environmental and occupational history and exposure data.
Computer-Based Learning. A variety of interactive computer programs have been developed that focus on clinical problems in environmental and occupational medicine, and these problems can be used to enhance students’ environmental and occupational history-taking skills. Students can work through computer-based cases, which can be loaded onto the computers generally used by them. Because the development of sophisticated computer-based instruction takes time, money, and considerable expertise, faculty are encouraged to identify and use existing resources.
Written Material. Students may be more inclined to remember to include environmental and occupational information in their history-taking if they understand the relevance and importance of the exercise. Several excellent journal articles, some based on actual cases, are available and can be assigned as required reading. The ATSDR case study on “Taking an Exposure History” (see Appendix A) is a good example that can also be used. Additionally, written history and physical examination forms can be modified to specifically require the elicitation of environmental and occupational exposure information (Box 6 provides an example of the importance of history-taking).
Although history-taking skills are generally first taught in medical interviewing and introduction to clinical medicine courses, history-taking competence is developed over time outside the classroom during encounters with patients. Faculty interest, awareness, and reinforcement are critical elements in ensuring that environmental and occupational history-taking skills are practiced, developed, and maintained. In clinical clerkships, this can occur in a variety of ways.
Box 6. Acute Lead Poisoning
A 46-year-old white male with a history of appendectomy at age 12 and partial small bowel obstruction at age 37 presented to the emergency room with cramping abdominal pain radiating to his back which gradually had appeared and worsened over one week. He also complained of nausea, headache, fatigue, and aches in his forearms and wrists. He denied diarrhea or constipation. Physical exam was benign at the time, and the KUB showed a nonspecific gas pattern, so the patient was sent home with analgesic medication. Ten days later he returned to the E.R. with continued symptoms and constipation. Again he was sent home with analgesics and a laxative; follow-up exams included a barium enema and an upper GI series with small-bowel follow-through, both of which were normal. He returned two more times with steadily worsening pain and constipation. On the fourth visit his abdomen was notably tender to palpation and there were decreased bowel sounds. The patient went on to receive an abdominal CT scan and finally an exploratory laparotomy before any of the medical staff queried him on his hobbies.
The patient had recently purchased a 150-year-old house, which he was renovating completely. He was sanding the paint by hand, wearing a simple dust mask, and living and eating in the areas where he was working. His blood lead level was 130 µg/dl.
Lead poisoning is an important cause of abdominal pain and is not uncommon among painters and people renovating homes. The mechanism is thought to be neuropathic, and is characterized by a diffuse cramping in the presence of a fairly benign physical exam. Lead poisoning should always appear in the differential diagnosis of abdominal pain: it can save unnecessary tests and even unnecessary surgery.
Adapted from a case presented by Rose Goldman, M.D., M.P.H. during Occupational Medicine Grand Rounds at the Harvard School of Public Health on 10/8/93.
See also case studies 18 and 19 in Appendix C.
Morning Report. Attending physicians can emphasize and reinforce the importance of environmental and occupational histories and exposures by routinely asking students about them during morning report. They can also use the cases presented to encourage further learning about environmental and occupational exposures and health effects.
Conferences. Residency programs hold conferences for their house staff, which rotating medical students normally attend. Again, case-based discussions can stress the importance of environmental and occupational histories and exposure information in contributing to the differential diagnosis, treatment, and management of patients.
Site Visits. The relevance of understanding a patient’s living and occupational environments can be enhanced by requiring students to visit a patient’s home, workplace,
or neighborhood. Site visits allow students to observe and experience their patients’ living and working conditions in a way that is not possible in the office or hospital setting, even with a good history. One experience in a blatantly unhealthy environment or an industrial facility can make a lasting impression on students. This strategy may be easier to use in ambulatory clerkships.
Written Material. At the beginning of each clerkship, students can be given a list of conditions or presenting complaints frequently encountered during the clerkship that may be environmentally related. They can be told that they will be specifically evaluated on the environmental and occupational histories taken from patients with those conditions or complaints. Examples include dyspnea, chronic fatigue, pulmonary fibrosis, poor school performance, and skin rashes.
Competency 4. Graduating medical students should be able to identify and access the informational, clinical, and other resources available to help address patient and community environmental health problems and concerns.
Information about resources can be provided in almost any setting, including clinical clerkships. Some examples follow (see also Appendix D).
Written materials that supplement and illustrate the clinical relevance of basic science concepts can include information on resources. For example, a clinical correlation on lead poisoning used to supplement material on heme synthesis can include information on the Centers for Disease Control and Prevention (CDC) guidelines, federal, state, and local agencies with toll-free hotlines, the name and telephone number of the medical school’s expert on lead poisoning, and sources of patient education material on lead. Similar types of “resource sheets” can be developed to provide information to students in their clinical clerkships. These resource sheets can focus on the types of problems or issues frequently encountered in a specific clerkship. For example, for a clerkship in family medicine, a resource sheet on indoor air contaminants would be useful to help parents of asthmatic children or patients with concerns about the air quality in their homes or workplaces.
Students can be placed with agencies, organizations, or specialists that deal with environmental and occupational issues in a longitudinal or block manner to enhance their understanding of these issues and the role of community resources in addressing them. Possible placement opportunities include state and local health departments and environmental agencies; environmental advocacy groups; local industry; labor unions; local chapters of cancer, heart, and lung societies; poison control centers; and environmental and occupational medicine specialists’ practices. These types of placements may be possible during community or preventive medicine courses, as well as during the summer between the first and second years. They can also form the basis of electives in environmental or occupational medicine for students with special interest in the field.
Problem-Based Learning, Clinical Precepting
In working up or reporting a case with a possible environmental connection, preceptors and attending physicians can ask students to obtain additional information or assistance. For example, an attending physician (or resident) could direct a student to identify and call a local expert in lead neurotoxicity; they could be told to investigate the health effects of a particular substance; or the small-group preceptor could suggest that students investigate the availability of local resources and determine what these resources can provide.
Competency 5. Graduating medical students should be able to discuss environmental risks with their patients and provide understandable information about risk-reduction strategies in ways that exhibit sensitivity to patients’ health beliefs and concerns.
Communication Skills and Interviewing Courses
In courses that use simulated patients to help teach communication and interviewing skills, the patients can be instructed to display various degrees of concern about potential environmental exposures. Evaluation and feedback can include commentary on a student’s listening and counseling skills and their sensitivity to the patient’s concern about environmental exposure(s). The student can be expected to validate the patient’s
concern, avoid the temptation to dismiss the environmental concerns in favor of a focus on life-style risk factors, avoid making the patient’s fear or concern seem irrational, and explain the degree of uncertainty inherent in medical risk assessment.
Epidemiology and Preventive Medicine Courses
Lectures and Supplementary Written Materials. Environmental and occupational factors can be easily included when teaching students how to characterize risk and identify preventive measures to reduce both population and individual risks. Journal articles that report epidemiologic studies of environmental and occupational diseases can be used to stimulate discussion of prevention and risk reduction (see Box 7). Handouts can be prepared that familiarize students with the range of risk-reduction strategies applicable to environmental and occupational hazards, from environmental modification to the provision of personal protective equipment and medical screening programs.
Workshops and Small-Group Sessions. Students can discuss environmental and occupational risk-reduction strategies and practice their counseling skills in small-group workshops that use cases, clinical problems, or role playing.
Basic Science Courses or Problems
Sessions or written materials used to supplement basic science concepts can include information on appropriate risk-reduction strategies. For example, a clinical correlation to basic science material on allergen-mediated asthma and anaphylaxis could address the issue of latex allergy in hospital workers and provide information on possible risk-reduction strategies, such as the use of nonlatex gloves. Similarly, a clinical correlation to basic science material on heme synthesis could address ways to reduce lead exposure among children or bridge painters.
Dust from latex gloves is a significant occupational aeroallergen (Institute of Medicine, 1993b).
Preceptors can be encouraged to require students to ask and counsel patients about
workplace and environmental risks. Students can then be observed and evaluated on this skill.
Box 7. Methylmercury Poisoning (Minamata Bay)
A 14-year-old boy living in a small city in Japan went to a local hospital in July of 1958 with recent onset of a number of neurological symptoms. He had numbness around his mouth and in his hands and feet; he was also increasingly clumsy and had difficulty buttoning his clothes and handling his chopsticks. Over several weeks he developed a staggering gait and became increasingly deaf. He also had a diminished attention span. At no time did he have a headache, fever, or stiff neck.
On physical exam he was markedly ataxic and dysarthric, his behavior was inappropriate to his age, and he had excessive salivation. The boy’s visual fields were constricted peripherally, through fundoscopic exam, and eye movements were normal. There was no nystagmus and muscle strength was normal. Reflexes were slightly diminished, more on the left than the right. Babinski was positive on the left and negative on the right. An unintentional tremor was present, and finger-to-nose and heel-to-shin tests were both abnormal.
The boy was one of over a hundred people struck by acute methylmercury poisoning after eating fish caught in Minamata Bay. A nearby vinyl chloride production plant had been dumping untreated chemical waste into the bay for years. The mercury in the waste made its way into the food chain, finally reaching concentrations sufficient to cause acute poisoning in those who consumed fish from the bay. Methylmercury primarily affects the central nervous system. Post mortem examination on fatal cases revealed cerebral edema, cerebellar atrophy, and diffuse cellular degeneration particularly in the granular layer of the cerebellum. Today mercury is found in some fungicides, disinfectants, some industrial cites, and (in low concentrations) in seafood throughout the world.
Adapted from Kurland et al. (1960).
See also case studies 21 and 22 in Appendix C.
Competency 6. Graduating medical students should be able to understand the ethical and legal responsibilities of seeing patients with environmental and occupational health problems or concerns.
Although not typically covered in ethics courses, the ethical dimensions of identifying, managing, and preventing cases of environmental and occupational disease can be discussed, as can physicians’ legal responsibilities. For example, cases or journal articles can be used to illustrate and discuss physicians’ ethical responsibilities for reporting serious environmental and occupational problems dealing with suspected hazards, protecting confidential information, and handling conflicting responsibilities to patients, employers, insurers, and others.
Community and Preventive Medicine and Public Health Courses
Courses in community and preventive medicine and public health provide opportunities to introduce students to legal and ethical concepts relating to environmental and occupational health. For example, community laws relating to waste disposal, recycling, or smoking in public places can be discussed, as can state and federal disease reporting laws, and toxic substance exposure registries.
Legal and ethical issues most frequently arise in the course of patient care, so the clinical clerkships are some of the best avenues for making students aware of their legal and ethical responsibilities. These types of issues commonly arise in the context of workers’ compensation, disability evaluations, return-to-work notes, incidents of environmental contamination (e.g., Love Canal), or an acute exposure to a toxic substance.
Clinical case conferences, and even Grand Rounds, are excellent vehicles for raising the legal and ethical issues inherent in many environmental health problems. When presenting or discussing a clinical case involving environmental or occupational exposures, faculty can incorporate the legal and ethical elements, thereby highlighting the inseparability of these issues.
Love Canal, New York is the site of one of the most well-known community hazardous waste stories in the United States. During the 1940’s, approximately 22,000 tons of chemical manufacturing wastes containing dioxins, polychlorinated biphenyls, and other hazardous compounds were dumped and later buried in the canal. Later, a housing development was built on the site, and in the 1970’s, residents began to notice unusual odors and oily puddles around their neighborhood. The federal government declared the site a disaster area and removed the residents from their homes (Upton and Graber, 1993).
Use of standardized patients would be ideal for helping students become more effective communicators within a context that, depending on the patient and the case, is sensitive and laden with socioeconomic, ethical, and legal issues.
ENHANCING FACULTY AWARENESS
As noted at the beginning of this chapter, any effort to integrate environmental health into the medical school curriculum requires faculty interest, commitment, and competence. Because the existing pool of medical school faculty with expertise in environmental medicine is exceedingly small, both long- and short-term strategies for expanding basic and clinical science faculty resources in this area must be pursued.
Some Long-Term Strategies
In the long term, more young scientists and physicians must be recruited into the area of environmental medicine. To develop a basic level of competence in all medical school and residency program graduates, the number of role models on the faculty must be expanded. As in other disciplines, possible incentives in environmental health are both economic and non-economic in nature. The field must be attractive, providing both personal satisfaction and economic opportunities to those who pursue it, and individuals must be made aware of the field and its potential for professional growth, development, and economic opportunity. Throughout their years of undergraduate education, students must be nurtured and encouraged to pursue their interest in the environment. In years K-12, there are now initiatives to develop students’ environmental awareness and literacy. At the college level, faculty could build on this awareness in their courses and in the counseling they do with pre-med students and students interested in pursuing
graduate degrees. Nursing schools and other health profession training programs can introduce students to career opportunities in environmental health. After college, adequate training support and stipends would make it easier for medical students and residents to pursue advanced training in occupational and environmental medicine, as would environmentally-focused research fellowships and traineeships for graduate students in the basic sciences. Beyond this, however, these newly trained professionals must be assured of continued support for their environmental health research and teaching activities. If this support is lacking, new faculty members will have considerable difficulty sustaining their work in the field. Thus, the committee strongly supports the recommendations for expanding environmental health research made by the IOM in 1988 (Institute of Medicine, 1988), as well as expanding environmental health teaching activities. Expanding research, education, and training becomes more important as we witness the continued pollution and degradation of our environment and experience the increasing public concern about possible related health effects.
Some Short-Term Strategies
Despite its importance, we need not wait until an expanded cadre of experts in environmental medicine is in place to begin integrating an enhancement of environmental medicine into medical education. Most medical schools already have faculty with at least some expertise in environmental medicine and who would be interested and willing to assist. Thus, a helpful short-term strategy would be to identify such a person who could serve as a champion for environmental medicine in the school and among the faculty. In schools with existing programs or expertise in environmental or occupational medicine, this champion may be easily identified. In schools without existing programs, this champion may be a respected teacher or clinician, prominent investigator, or activist in curricular reform from any discipline or department. The champion may also be a faculty member who has a personal interest in the environment because it directly or indirectly relates to his/her area of research, or because he/she has a personal concern about the environment—be it preservation of the environment or protection of human health. If not champions, these same individuals may serve as important allies in any effort to integrate environmental medicine into the curriculum. Because environmental health covers a wide range of topics—from toxic substances and infectious agents to particular diseases, population growth, and family planning—most medical school faculty will already have some knowledge and/or interest within their own disciplines about environmental factors and related medical conditions. This knowledge and/or potential interest in environmental and occupational health should be identified (perhaps as part of the inventory described at the beginning of this chapter) and nurtured by encouraging faculty to incorporate an environmental medicine focus into the courses and clerkships they teach.
Among basic science faculty, an opportunity to nurture this interest may lie in an increasing concern with making courses more clinically relevant as a way to enhance long-term learning as well as course satisfaction among medical students. In the process of modifying the basic science curriculum, for example, a champion with expertise in environmental and occupational medicine could review course syllabi and materials with course directors to identify possible access points within the course that would be amenable to and enhanced by introducing environmental and occupational medicine issues. With some assistance and without too much effort, the course director could then incorporate clinically relevant material, as well as opportunities to discuss prevention strategies, in lectures or small group problem-solving sessions. As illustrated in Appendix B, this integration can occur in almost every basic science discipline.
These same faculty can be encouraged to pursue the environmental connections in their own research, especially if sources of support can be identified. There is no paucity of research needs in this area, and the potential for interdisciplinary collaboration is substantial.
Among clinical faculty, efforts to increase the knowledge of, and/or interest in, environmental and occupational medicine can take several forms, but the fundamental appeal should be to assist them in responding to patients’ questions about environmental hazards, counseling them appropriately, and providing effective treatment. With increasing public concern about the environment, physicians more frequently encounter patients with questions about potential exposures, or symptoms that patients attribute to occupational or environmental conditions. Thus, clinical faculty may find it in their interest to learn more about these issues so they can adequately address them in their practice and in their teaching. This can be accomplished, in part, through presentations at departmental conferences and rounds, formal faculty development programs, the development and provision of brief, clinically relevant teaching materials for use in specific clerkships, and personal mentoring of interested junior faculty. Additionally, faculty with expertise in occupational and environmental medicine can serve as educational role models—perhaps offering to attend an occasional morning report or afternoon case rounds.
Clinical faculty, especially junior faculty, may seize on the opportunity to develop themselves as institutional or local resources in environmental health for their clinical colleagues. This may enhance their prestige in the community and among students who may more fully appreciate the importance of the environment to human health. Of course, this may require institutional support for these faculty members to develop their own competence.
The single clinical skill the committee views as the key component of an environmental medicine curriculum is the ability to obtain a meaningful environmental (including occupational) history. As with any clinical skill, its elements must be specified, demonstrated, practiced, and reinforced by faculty who are comfortable and experienced in its uses. Efforts to encourage faculty to focus on this skill should be aimed at those
Students should be made to realize from the beginning of their clinical studies that the diagnosis in a large majority of illnesses can be made on the basis of a searching history, a thorough physical examination, relatively simple laboratory determinations, and the thoughtful consideration of the problem presented (Rappeleye, 1932).
involved with precepting in ICM (Introduction to Clinical Medicine) courses and at faculty preceptors in clinical clerkships, whether they are hospital or community based (see Appendix B, ICM Section). In either case, guidelines for faculty could include information on taking an environmental and occupational history, with an explanation of why and how each element of the history is useful and important for arriving at a diagnosis or developing a clinical plan of action. The guidelines can be developed around an example of a common patient complaint in a particular discipline to better illustrate the relevance of the environmental and occupational history to the practitioner. The guidelines could also include samples of environmental/occupational history forms, checklists, or formats for evaluating students’ history-taking skills (Appendix A contains the ATSDR case study on “Taking an Exposure History,” which is a good example). In those schools that hold orientation sessions for precepting faculty, a standardized patient could be presented to illustrate the way an environmental and occupational history should be taken. Alternatively, preceptor orientation could include written materials and one of several existing videotapes that demonstrate how to take a sufficiently detailed history in a given clinical setting.
In general, efforts to enhance faculty awareness of environmental medicine should focus on those who teach and practice primarily in ambulatory settings, particularly those with a primary care practice. Because information and resource issues are relevant only when faculty are faced with a clinical problem, problem-solving approaches should be the mainstay of this effort. Illustrative examples can be prepared and distributed to preceptors, along with concise descriptions of key agencies, organizations, and professionals easily accessible by telephone, that can provide appropriate and timely information in the evaluation and management of patients with potential environmental exposures or illnesses. As a first step, faculty could be informed of the broad-based information currently available on environmental exposures at most nationally certified poison control centers.
Many clinical faculty lack the skills needed to counsel patients about environmental and occupational risks. As a result, those serving as preceptors might be hard pressed and perhaps uncomfortable in demonstrating these skills or supervising students in their patient encounters. In such cases, standardized patients, role-playing, dramatized presentations, and videotapes, alone or in combination, can be used to raise faculty competency. Clearly, the medium and the educational setting are dependent on the organization and resources available to those responsible for ensuring appropriate faculty
supervision of student education.
Finally, it should not be forgotten that students can affect faculty awareness of issues. For this reason, we need innovative ways to capitalize on student interest in the environment and health extracurricularly. For example, schools could support the establishment of environmental health student interest groups that might initiate environmentally related activities (e.g., recycling programs at the school) or host other events with invited speakers. Schools and agencies could identify and support summer internships and student research projects in environmental medicine. Such student initiatives would influence faculty awareness and help engender enthusiasm that could affect changes in the curriculum.
CONCLUSIONS AND RECOMMENDATIONS
Fundamental to the recognition, evaluation, and resolution of environmentally related illness and injury will be the availability of informed physicians who understand the relationship between the environment and health and who can provide care and counsel to their patients and their communities potentially at risk for, or already affected by, environmentally related illness and injury. Achieving this level of competence will require the development and delivery of educational programs that give physicians the knowledge, skills, and attitudes needed to deal effectively with environmental factors in both clinical and public health contexts.
The strategies for integrating environmental medicine into medical education proposed in this report are economical as well as effective. They require no new curriculum time and few, if any, additional resources.
Integrating the Curriculum
Environmental medicine may already be addressed in unexpected places in the curriculum. Thus, it will be helpful for medical schools to inventory the content of their educational programs throughout the four years of medical education and assess their relevance to the objectives suggested in this report. Where deficiencies exist, materials such as those presented in this report can facilitate and enhance the integration of environmental medicine concepts. The needed instructional materials and basic concepts can be included in existing lecture series, as part of existing courses, or as supplements in problem-oriented case discussions. The establishment or enhancement of this content in the school’s curriculum may also facilitate efforts to integrate the basic and clinical sciences, as well as helping to promote stronger relations between the medical school and the community in which it resides.
The actual content used to help students develop the six competencies will vary,
reflecting faculty interest and expertise, student interest, the conditions and risks in the local community, and institutional resources and constraints. Some students will develop these competencies by learning about heavy metals, while others may apply them to cancer or respiratory diseases. In all cases, the underlying goals should be the same—to teach students about causation, history-taking, and disease prevention.
In order to ensure adequate attention to environmental medicine in medical education, an enhanced awareness of the importance and integral nature of environmental medicine is needed among all faculty, as well as an increase in the number of medical school faculty with expertise in environmental medicine. The committee supports previous IOM reports that noted a severe shortage of such personnel and made recommendations for increased funding to support faculty development (Institute of Medicine, 1988; 1991).
The development of faculty as educators in environmental medicine requires more than simple encouragement to integrate the topic into their teaching. Faculty need to understand the relevance of environmental medicine to patient care, to the health of the public, and to their own disciplines. They need concrete examples of innovative and interactive materials and methods for incorporating environmental medicine into their teaching without significantly increasing their time commitment. They also need colleagues in their own and other disciplines to share their commitment to and enthusiasm for creating an environmental focus in their courses and teaching programs. Professional associations and organizations can and should play an important role in advancing this interest in environmental medicine. Position papers on the relevance of environmental medicine to their particular disciplines or specialties would be helpful in this regard, as would articles in their journals that emphasize the critical relationship between environmental health and physician involvement.
In addition, faculty should be encouraged, supported, and rewarded for their teaching activities—in this case, their teaching of environmental medicine. Establishing awards for innovative teachers/educators is one mechanism. Other possibilities include short-term faculty internships/projects and the development and implementation of traveling faculty development programs. Federal support for such programs should be established within the Department of Health and Human Services and the Environmental Protection Agency.
Because what is learned in the classroom must be reinforced in the clinical setting, it should be made easy for clinical faculty to routinely consider environmental and occupational factors in their patient care activities. Many things are needed to facilitate this including: making environmental history-taking reimbursable; developing usable forms and data systems; establishing a quick source of information and/or referral
Experience indicates that the commitment to education of deans and departmental chairmen greatly influences the behavior of faculty members in their institutions and their departments. By their own attitudes and actions, deans and departmental chairmen should elevate the status of the general professional education of medical students to assure faculty members that their contributions to this endeavor will receive appropriate recognition (Association of American Medical Colleges, 1983).
resources; and expanding continuing medical education activities in this area.
At the outset the committee restricted its discussions and recommendations to undergraduate medical education, but it soon became apparent that environmental and occupational medicine should be a part of the full continuum of medical education, including postgraduate training and the continuing education of practitioners. To the extent that medical schools assume responsibility for the continuum of medical education, environmental and occupational education should be a part of their overall curriculum. Efforts to enhance medical practice by integrating the six competencies into continuing education should be expanded, with appropriate emphasis on community issues.
Many important, continuing medical education initiatives in environmental medicine are currently available or in development. The American College of Occupational and Environmental Medicine, for example, has developed a comprehensive, 18-hour environmental medicine curriculum that can be adapted to a variety of educational formats. This curriculum course is offered to interested participants at their annual meeting. The Agency for Toxic Substances and Disease Registry has supported the development of a course in pediatric environmental health (California Public Health Foundation, 1992), as well as a series of case studies in environmental medicine (see Appendixes A and C). Innovative educational methodologies have been developed by recipients of Preventive Pulmonary Academic Awards given by the National Heart, Lung, and Blood Institute. The National Institute of Environmental Health Sciences’ Environmental/Occupational Medicine Academic Award recipients are developing educational materials and methodologies and history-taking techniques to facilitate the integration of environmental and occupational medicine into the medical school curriculum. A list of medical schools that currently receive these awards and have available expertise and information in environmental medicine appears in Appendix D (see pages 917–918 and 920). These activities, and others like them, have been very useful in the development and integration of environmental medicine concepts and materials into medical education. Continued support for these activities is needed and
should be expanded if possible to help ensure the enhancement of environmental medicine in medical education. Expansion activities should include establishment and support of: (1) an environmental medicine speakers bureau, with speakers who can address the concerns and issues of specific disciplines, e.g., pediatrics, obstetrics, neurology, etc., and (2) a database of curricular materials and activities for use by faculty and students.
Even when undertaken with the best of intentions, curricular reforms can easily become more symbolic than substantive if they are not “kept honest” through careful evaluation. The committee strongly recommends that medical schools develop a plan for evaluating their progress in implementation as they begin to integrate environmental and occupational medicine into their curricula. The evaluation plan should be a serious part of the overall effort, not an afterthought. In some cases, it may be possible to develop a rigorous plan for systematic evaluation, possibly with outside technical assistance; in other cases, the evaluation will be more informal. Either way, a genuine commitment is vital to check up on the innovation as it proceeds.
The curricular changes recommended here must necessarily be tailored to each medical school’s particular circumstances. In addition, in each school the effort is likely to go through considerable evolution before stabilizing, with trial and error around specific changes. Therefore the approach to evaluation should be a comprehensive, flexible one that includes both process evaluation and impact assessment. The “process” part of the evaluation plan should include (a) needs assessment aimed at understanding the context into which the changes must fit, and (b) program monitoring aimed at tracking the implementation of the changes. The “impact” part consists of effectiveness studies aimed at measuring the program’s success in meeting its objectives. At a later stage, it might also be appropriate to undertake some efficiency studies to determine the most cost-efficient ways of effectively delivering training in environmental medicine.
For needs assessment, some useful focal points for examination include the following:
An inventory of environmental medicine content already available in courses and related clinical training.
Identification of faculty expertise in environmental medicine, broadly defined.
Assessment, through surveys or focus groups, of the faculty’s receptivity to the proposed innovations. Are they interested in the new material? Do they feel competent to teach it? Are they willing to teach it? Do they want to modify or extend it? Can they suggest any special faculty training or support needs, any barriers to change that could be removed, any incentives that could be offered?
Assessment, through surveys or focus groups, of students’ interest in the proposed
innovations. Do they recognize a need for this training, or do they regard it as an unwanted extra? What training format would work best from their perspective?
Assessment, through surveys or focus groups, of commitment to the proposed changes on the part of the school’s leadership. How enthusiastic are they about the changes? Do they anticipate any problems in implementation? How much tangible institutional support will they give to the curricular changes being proposed?
An inventory of relevant local resources and opportunities for community placements, interdisciplinary connections, and inter-institutional cooperation.
For program monitoring after some of the changes have begun to take effect, two levels of program operation should be examined: (a) the system of delivering the new training, and (b) patterns of participation in the new training. At the first level, the task is to document exactly what new content is being offered and through what mechanisms it is being provided. At the second level, the task is to analyze what part of the student body is being exposed to the new training, and which faculty are involved in delivering it. Since the actual program operation may differ from the intended program operation, the monitoring data should wherever possible be collected through direct observation and inquiry rather than from documents that describe what ought to be happening. The monitoring effort should include some open-ended exploratory data-gathering in order to detect unanticipated developments or problems. To provide useful program oversight, program monitoring should ideally be carried out at least once a year.
To evaluate program effectiveness (or “impact”), a central concern would be the measurement of student performance on the six competency-based leaning objectives described in this report. The simplest but methodologically weakest approach is simply to assess the extent to which graduating students demonstrate the six competencies. This establishes that they know the desired content, but not necessarily that they learned it as a result of the training provided, since they could have had these competencies all along, or developed them through experiences outside the program. The case for program effect could be strengthened by adding a “before” measurement of the six competencies among incoming students, to be compared with an “after” measurement at the point of graduation. An even stronger case for program effect would come from an evaluative study with experimental design, in which before-after competency measurements for students receiving the environmental medicine training are contrasted with comparable measurements for a control group that does not receive the training. Because practical constraints often make experimental design infeasible, setting up a valid effectiveness study can be a real methodological challenge. Fortunately, a variety of quasi-experimental designs have been worked out to approximate the logic of experimental control in evaluating program effectiveness. These are described in numerous readily available texts on evaluation research (Cook and Campbell, 1979; Patton, 1990; Rossi and Freeman, 1993; Schalock and Thornton, 1988).
Evaluating medical students’ competencies in environmental medicine at the point
of graduation is clearly very important. But will the graduates retain these competencies over time? The long-term effect is much harder to evaluate. One approach, supported by this committee, is for the National Board of Medical Examiners and the Federal Licensing Examination to incorporate into their certifying examinations the six competencies described in this report.
Probably the most meaningful way of evaluating program effect would be to assess medical graduates’ actual use of the six competencies in their post-graduation practice. Are they finding it possible to put their environmental medicine training into practice—and if not, why not. This kind of assessment, which might be done through a survey of graduates, could be carried out only after the training had been in place for some time.
Other potential program effects that might be examined in individual medical schools include changes in faculty attitudes, activities, and competencies related to environmental medicine; changes in administrative awareness and support for environmental medicine; and changes in the medical school’s patient services and community activities related to environmental medicine.