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Executive Summary

A pregnant woman voices a concern to her obstetrician during a routine prenatal visit. It seems that several women in her neighborhood have recently had babies with a variety of birth defects. She worries that the recently discovered well-water contamination in her community may be responsible, and she wants to know what she should do.

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A 24-year-old salesman consults his physician with a two-month history of fatigue, joint pain, and occasional gastrointestinal symptoms. Approximately three months ago, he bought an 80-year-old house and started renovating the interior.

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The public is increasingly concerned about potential environmental health hazards and often wants answers to very concrete questions, such as: Is the water safe to drink? Could my miscarriage be due to my work environment? What is the likelihood of having a child with birth defects due to exposure during pregnancy to my computer’s electromagnetic field? (see Box 1.) Are the pesticides used on fruit harmful? Is living close to power lines harmful? Patients ask their physicians these questions because, in general, they trust them and value their advice. Unfortunately, physicians often lack adequate, appropriate information and training with respect to environmental risks and health.

The integral relationship between the environment and health necessitates the active participation of knowledgeable physicians in both clinical and community contexts. In 1988, the Institute of Medicine (IOM) examined the role of primary care physicians in occupational and environmental medicine and called for enhanced physician training and education in this area. Noting that primary care physicians are often the health professionals of first contact for patients with environmentally related illnesses, the IOM suggested that, “as a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals for follow-up” (Institute of Medicine, 1988:63).

Today’s challenge is to help medical students develop the knowledge and skills they will need to deal effectively with environmental health issues in clinical care and public health contexts. Doing this within the confines of an already stressed and overcrowded



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Environmental Medicine: Integrating a Missing Element into Medical Education Executive Summary A pregnant woman voices a concern to her obstetrician during a routine prenatal visit. It seems that several women in her neighborhood have recently had babies with a variety of birth defects. She worries that the recently discovered well-water contamination in her community may be responsible, and she wants to know what she should do. * * * A 24-year-old salesman consults his physician with a two-month history of fatigue, joint pain, and occasional gastrointestinal symptoms. Approximately three months ago, he bought an 80-year-old house and started renovating the interior. * * * The public is increasingly concerned about potential environmental health hazards and often wants answers to very concrete questions, such as: Is the water safe to drink? Could my miscarriage be due to my work environment? What is the likelihood of having a child with birth defects due to exposure during pregnancy to my computer’s electromagnetic field? (see Box 1.) Are the pesticides used on fruit harmful? Is living close to power lines harmful? Patients ask their physicians these questions because, in general, they trust them and value their advice. Unfortunately, physicians often lack adequate, appropriate information and training with respect to environmental risks and health. The integral relationship between the environment and health necessitates the active participation of knowledgeable physicians in both clinical and community contexts. In 1988, the Institute of Medicine (IOM) examined the role of primary care physicians in occupational and environmental medicine and called for enhanced physician training and education in this area. Noting that primary care physicians are often the health professionals of first contact for patients with environmentally related illnesses, the IOM suggested that, “as a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals for follow-up” (Institute of Medicine, 1988:63). Today’s challenge is to help medical students develop the knowledge and skills they will need to deal effectively with environmental health issues in clinical care and public health contexts. Doing this within the confines of an already stressed and overcrowded

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Environmental Medicine: Integrating a Missing Element into Medical Education Box 1. Reproductive Hazards and VDT Exposure A 31-year-old woman, gravida 1, para 0, presents to her obstetrician at six weeks’ gestation with concerns about her home computer. She is a graduate student at the local university and is working on her thesis. This work requires that she use the computer for up to six hours per day. She has heard that there may be an association between electromagnetic fields from video display tubes (VDTs) and adverse pregnancy outcomes. She does not want to take any risks, but she hopes to finish her thesis before the child is born. She asks her physician’s opinion of the literature on VDT exposure and birth defects. There have been many reported clusters of women working with VDTs in office settings who gave birth to children with birth defects. Reported defects were widely heterogeneous, including clubfoot, congenital heart defects, neural tube defects, and cleft palate. In addition, clusters of prematurity and spontaneous abortion have been reported. VDTs emit nonionizing radiation: light, radiowaves, and microwave radiation. While there is some concern about the association of nonionizing radiation in the form of electromagnetic fields and the risk of hematologic tumors, brain tumors, and adverse reproductive outcomes, the evidence is still very mixed. The evidence of an association between electromagnetic fields and specific cancers (e.g., leukemia, brain tumors) is much stronger at this time than the evidence of an association between these fields and reproductive risk. Most physicians do not feel that VDTs pose a significant risk of adverse pregnancy outcomes. Patients’ concerns about potential occupational or environmental exposures during pregnancy must always be taken seriously. If the clinician does not know the medical literature on the exposure in question, it is imperative that he or she research the issue before simply reassuring the patient. Maternal exposures to many things clearly increase the risk of adverse pregnancy outcomes. Lead, solvents, ethylene oxide, glycol ethers, carbon monoxide, radiation, prolonged standing, and drugs such as thalidomide and alcohol are all clear examples of reproductive hazards. Caution and awareness of the possibility of new reproductive hazards is important to prevent unnecessary reproductive tragedies. Adapted from Bentur and Koren (1991), Paul and Himmelstein (1988). See also case study number 53 in Appendix C for more information on reproductive and developmental hazards. four-year undergraduate medical curriculum that has been described by some as unresponsive to societal changes and needs (Abrahamson, 1978; Marston and Jones, 1992; Pew Health Professions Commission, 1991) and reinforcing and expanding this knowledge and these skills during postgraduate residency training is a formidable challenge. Although efforts at curriculum reform have failed in the past, medical education may be embarking upon a new era. There are renewed calls for change; those calls and the

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Environmental Medicine: Integrating a Missing Element into Medical Education current evolutionary changes that are occurring in the health care system could be important driving forces for curricular change. Such change could include the integration and enhancement of environmental health in the curriculum. To help prepare physicians for the emerging awareness of environmental health issues and their roles in addressing them, principles and concepts of environmental health must be taught and continually reinforced throughout undergraduate and postgraduate medical education and training. The committee believes, however, that specifying what should be taught is not as useful as describing what students should know and be able to do at the end of their training. With such competency-based objectives in mind, the committee recommends that all graduating medical students have the knowledge and skills listed below. 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. Graduating medical students should be able to recognize the signs, symptoms, diseases, and sources of exposure relating to common environmental agents and conditions. Graduating medical students should be able to elicit an appropriately detailed environmental exposure history, including a work history, from all patients. 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. 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. Graduating medical students should be able to understand the ethical and legal responsibilities of seeing patients with environmental and occupational health problems or concerns. Consensus on the goals and content of a curriculum, such as the six competency-based learning objectives above, is a necessary but insufficient prerequisite for training medical students and residents in environmental medicine. Reasoned arguments for such a curriculum cannot alone ensure that it will be implemented. Other factors that affect the extent, quality, and success of implementation efforts include the availability of faculty time in an already overcrowded curriculum; support for teaching and curricular innovation; competing faculty and community concerns or interests; and budgetary constraints. Any strategy for implementing changes in the curriculum must be sensitive to these factors and include action at many levels. At the medical school level, there is a need for knowledgeable and enthusiastic teachers, exciting teaching materials and methods, and creative and judicious use of

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Environmental Medicine: Integrating a Missing Element into Medical Education curricular time. This will require that administrators who recognize the importance of the curriculum support ongoing faculty development and provide adequate rewards for the teaching faculty. All this may necessitate activities at many other levels, for example, expanded initiatives by federal agencies, residency review committees, and professional organizations. Practice barriers, such as lack of reimbursement for preventive services, will also require attention. With these many counterpressures and demanding complexities in mind, we present a practical and simple approach to integrating environmental medicine into the medical curriculum. 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 approach to achieving the competency-based objectives, but it seems to be the most appropriate as well given the pervasive and fundamental nature of environmental effects 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 those issues. As described in this report, instructors should be able to integrate environmental medicine into existing medical school courses and clerkships fairly easily. To ensure the progressive enhancement of competency in environmental medicine in medical education and practice, the committee makes recommendations for the continued funding and expansion of programs that currently support research and training, such as Academic Awards and Center Grants. This enhancement should build on the success of current programs and include adequate funding to support reasonable progress in curriculum development, faculty development, and continuing education. In addition to the current activities, the committee recommends that consideration be given to establishing (1) a database of curricular materials for faculty and students, and (2) a speakers bureau in environmental medicine. Information about these activities and resources should be disseminated with vigor to help ensure the integration of environmental medicine into medical education and practice. To facilitate integration and enhancement of environmental medicine in medical education, the report includes four appendixes that provide 55 case studies and other detailed information on available educational resources and teaching aids. Of particular utility will be the indexes in Appendix C, which guide the reader to cases in environmental medicine based on: (1) chemical agents and conditions, (2) medical school courses and clerkships/clinical rotations, (3) sentinel pathophysiological conditions, and (4) clinical signs, symptoms, and presenting complaints. The appendixes and case studies can and should be used to facilitate the integration of environmental medicine into both education and practice.