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4
Changing Medical Education

There is a growing consensus among medical educators in North America that both the content and structure of medical education require fundamental change (Anderson, 1993; Marston and Jones, 1992; Morris and Sirica, 1992; Pew Health Professions Commission, 1991). Despite this recognition, meaningful and sustainable change continues to be difficult to initiate. This chapter outlines the general nature of change in medical education and specific aspects of introducing environmental medicine into the medical school curriculum.

CALLS FOR REFORM IN MEDICAL EDUCATION

The integration of environmental medicine into the medical school curriculum fits nicely with recent calls to reform medical education. Over the past decade, numerous organizations, commissions, and foundations have proposed initiatives to reform the process, content, and structure of medical education in the United States (Enarson and Burg, 1992). A remarkable degree of consensus has emerged from these studies. In its own way, each report emphasizes the need for medical schools to place students at the center of their missions, and each urges the schools to prepare their students to meet the changing health care needs of the American public (Association of American Medical Colleges, 1992a). In characterizing the future U.S. health care system, the Pew Health



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Environmental Medicine: Integrating a Missing Element into Medical Education 4 Changing Medical Education There is a growing consensus among medical educators in North America that both the content and structure of medical education require fundamental change (Anderson, 1993; Marston and Jones, 1992; Morris and Sirica, 1992; Pew Health Professions Commission, 1991). Despite this recognition, meaningful and sustainable change continues to be difficult to initiate. This chapter outlines the general nature of change in medical education and specific aspects of introducing environmental medicine into the medical school curriculum. CALLS FOR REFORM IN MEDICAL EDUCATION The integration of environmental medicine into the medical school curriculum fits nicely with recent calls to reform medical education. Over the past decade, numerous organizations, commissions, and foundations have proposed initiatives to reform the process, content, and structure of medical education in the United States (Enarson and Burg, 1992). A remarkable degree of consensus has emerged from these studies. In its own way, each report emphasizes the need for medical schools to place students at the center of their missions, and each urges the schools to prepare their students to meet the changing health care needs of the American public (Association of American Medical Colleges, 1992a). In characterizing the future U.S. health care system, the Pew Health

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Environmental Medicine: Integrating a Missing Element into Medical Education Professions Commission projected a system that would be more oriented on health, would stress disease prevention and health promotion, and would be population based to respond to the increasing attention paid to social and environmental risk factors (O’Neil, 1992; Pew Health Professions Commission, 1991). In this context, the Pew commission articulated a responsibility for health professionals to understand, maintain, and improve community health and thus the need for future physicians to understand the societal and environmental determinants of health. Other studies have noted the need to shift the focus of medical education from acute to chronic conditions and from an infectious to a biopsychosocial model of health and disease (Association of American Medical Colleges, 1992a). Many of the reform proposals pose opportunities for integrating environmental medicine into medical education in the sense that: environmental medicine is responsive to the calls for cross-disciplinary teaching; environmental medicine melds basic and clinical science and reinforces the basic and biomedical sciences throughout the course of medical study; it moves training away from tertiary-care teaching hospitals and into the community; and it emphasizes student-directed, problem-based learning (Association of American Medical Colleges, 1992a,b; Marston, 1992; O’Neil, 1992). Environmental medicine is also central to primary care. Despite the plethora of studies, reports, and recommendations, however, actual efforts to respond to the calls for change have been less than noteworthy and successes have been few (Anderson, 1993; Enarson and Burg, 1992). There is, nonetheless, a steady and growing interest among medical schools in reform, presenting a window of opportunity for environmental medicine. The key to seizing this opportunity is realistic implementation strategies for importing knowledge about the environment and its role in health into mainstream medical education. Chapter 3 of this report described some potentially effective implementation strategies; the remainder of this chapter describes potential barriers and opportunities that may be encountered in attempting to modify medical school curricula. BARRIERS AND OPPORTUNITIES For decades, the basic structure of the medical school curriculum has changed very little. Medical school curricula, although superficially varied, are designed to prepare students for graduate medical education and practice. The four years of medical school are commonly divided into two years of discipline-oriented preclinical (basic science) studies followed by two years of clinical studies. Clinical education has traditionally occurred in the hospital, although students increasingly learn in outpatient, ambulatory care facilities. At many medical schools, the fourth year is primarily student-designed, and students spend much of their time in elective study. This period also involves time spent interviewing for future residency positions. To the extent that the preclinical and

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Environmental Medicine: Integrating a Missing Element into Medical Education clinical programs are temporally distinct, the integration of basic sciences with their clinical application is less than ideal. In response to concerns about traditional medical curricula, innovative new programs of undergraduate medical education have emerged within the past decade (Anderson, 1993). The content and structure of some of the new programs share some common features, each of which is relevant to an environmental medicine curriculum: more interdisciplinary courses that integrate basic and clinical sciences—an opportunity easily realized in environmental medicine; an emphasis on the mastery of biological concepts; content related to social and behavioral aspects of health and disease; and ambulatory and community clinical experiences that teach health care organization, practice, and financing. In addition, some of the new programs include experiences with problem-based learning and small group interactions with faculty, as well as more independent learning. While reports suggest that many medical schools are considering similar programs and some schools have already made significant changes in their curriculum, such change is far from universal. The majority of North American medical schools continue to use traditional programs, whose entrenchment is deep and resistant to modification. Even though the shortcomings of medical education have been identified and widely acknowledged for many years, several barriers appear to obstruct schools from making the changes they agree should be made. Some of these barriers are likely to be encountered by advocates for environmental medicine. Barriers Over the years, there have been many calls for curriculum reform, but structural barriers have hampered progress (Anderson, 1993). Medical education is still largely dictated by and compartmentalized into departments and disciplines, generally focused on information transfer rather than problem solving, reliant on traditional teaching methods, and overwhelmed by an ever-expanding knowledge base. In a report entitled Educating Medical Students: Assessing Change in Medical Education—The Road to Implementation, also known as the ACME-TRI report (Association of American Medical Colleges, 1992b), the Association of American Medical Colleges assessed the degree of change in medical education and identified barriers to successful change. The five most prominent obstacles found were: a lack of oversight for the educational program; limited resources and no defined budget for medical students’ education;

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Environmental Medicine: Integrating a Missing Element into Medical Education faculty inertia and a lack of incentive for faculty to teach; lack of leadership in the educational program; and lack of evidence that implementing the suggested changes will make the necessary improvements. These barriers were identified repeatedly by respondents to the ACME-TRI project survey and represent key elements that must be altered, or overcome, if meaningful change is to occur in the medical school curriculum, including the integration of environmental medicine. In any attempt to change the manner or content of instruction in medical schools, it is important to keep several realities in mind regarding time constraints and competing demands. First, the current academic reward system makes most members of the faculty reluctant, if not unwilling, to be involved deeply in teaching because it interferes with their academic careers. Despite the fact that interaction with students may well have been one of the most important factors in their choice of an academic career, most faculty members are under considerable pressure to seek research support, carry out research, and generate publications to support their progress up the conventional ladder of academic success. Second, those in clinical departments are required to generate much of their compensation through patient care. Third, all faculty participate in myriad, time-consuming committees and meetings for various academic, scientific, professional, and community causes. One of the key tasks for those committed to education is to establish a professional environment in which interested faculty members can implement new educational programs without adversely affecting their careers or penalizing their income or that of their department. All the recent studies of change in medical education acknowledge that resistance to change is partly attributable to the institutional matrix of discipline-based departments in which most medical education takes place and that is characterized by the three realities described above. Bloom (1988, 1989) describes a “corporate-style bureaucracy” in which departmental and individual autonomy, resources, and prestige are organized around the research enterprise and, increasingly, revenue-generating clinical services. One of the statements in the ACME-TRI report sums up this problem as follows: …department chairs acknowledge that medical students’ education is not a principal priority for their departments,…because of associated revenues and the importance of providing recognition for faculty members in their disciplines, [chairmen and faculty members] are more concerned with excellence in regard to graduate students, residents, research, and patient care. (Association of American Medical Colleges, 1992:3) It is important to understand that virtually all academic chairmen over the age of 50 have reached their prominent positions through the very systems now subject to change. Further, these chairmen inherited tenured faculty members who have also risen to senior ranks in these same long-standing pathways, involving many hours of classroom

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Environmental Medicine: Integrating a Missing Element into Medical Education exposure, many hours spent lecturing, and a habit of teaching facts rather than using factual information as a means of inspiring students to understand important concepts. Indeed, the ACME-TRI study found that the major constraint to establishing a central administrative structure with the authority to plan and manage the medical education program is the unwillingness of faculty members in various departments to relinquish their authority to determine the knowledge and skills that medical students should acquire. This privilege is defended even when department chairs acknowledge that medical student education is not a principal priority of the department. Proposals that involve the rebudgeting of funds and that provide a defined, centralized budget for medical student education also meet stiff resistance. However, pressure to develop central control could increase, especially with the accreditation standard set by the Association of American Medical Colleges’ Liaison Committee on Medical Education that requires central curriculum management. The standard states that: “There must be integrated institutional responsibility for the design and management of a coherent and coordinated curriculum. The chief academic officer should have available sufficient resources and authority to fulfill this responsibility” (Liaison Committee on Medical Education, 1991). Thus, the Liaison Committee has an opportunity to be an agent of change if it chooses to interpret strictly its own standards and exercise its authority in this fashion. Factors beyond the medical school itself also tend to sustain and reinforce traditional programs. Such factors include the dynamics of discipline-based scientific and medical societies, issues of public policy, and funding of education and health care. On some of these fronts, however, there are indications that the barriers may be coming down. Opportunities In the face of the barriers described previously, there are also some encouraging opportunities. This report describes three briefly: (1) an increased emphasis on prevention, (2) a paradigm shift in the knowledge base, and (3) a small but promising set of programs that support the development and integration of environmental medicine into medical education and practice. Prevention and Future Health Care The competency-based learning objectives set forth in Chapter 2 conform to several tenets underlying some of the current evolutionary trends in health care. Future systems of health care are likely to place more emphasis on the role of prevention and the need for accountability. In addition, the capacity of state and local public health agencies may be strengthened to help protect communities against communicable diseases and exposure

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Environmental Medicine: Integrating a Missing Element into Medical Education to toxic environmental pollutants, occupational hazards, harmful consumer products, and poor-quality health care, as well as to inform and educate health care consumers and providers about their roles in preventing and controlling disease. Responding to the evolutionary forces in today’s health care system, professional groups have further emphasized the need for and clarified a taxonomy of prevention in health care to include personal or clinical preventive services, community-based preventive services, and social policies for prevention (Partnership for Prevention, 1993). Applying this taxonomy to environmental risks and disease, Table 1 illustrates the range of potential roles for physicians in environmental medicine (see also the discussion in Chapter 1), as well as the salience of the recommended competency-based objectives. With or without substantial changes in the health care system in the United States, prevention is likely to play a larger role in the future practice of medicine, providing opportunities for the integration of-environmental medicine into both education and practice. Table 1. Some Examples of Components of Prevention in Environmental Medicine. Personal or Clinical Preventive Services Community-Based Preventive Services Social Policies for Prevention Taking environmental and occupational exposure histories, evaluating risk, and screening for detection of disease Providing individual and community education about environmental conditions, risks, and workplace health and safety Promoting regulatory policies to reduce environmental health hazards and increase work-place health and safety Counseling individuals about environmental and occupational health risks and building the knowledge, skill, and motivation to avoid risks and maintain healthy life-styles Evaluating and taking action to assure the availability of safe air, water, and food supplies, as well as healthy workplaces Supporting and promoting economic incentives to encourage environmental protection, clean technologies, and pollution prevention Intervening with chemoprophylactic agents Providing outreach services to identify individuals or populations with environmental and occupational health risks and to link them with appropriate services Advancing and supporting consumer product safety   SOURCE: Adapted from Partnership for Prevention (1993).

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Environmental Medicine: Integrating a Missing Element into Medical Education The Knowledge Base Recent progress in medical science may facilitate educational change by directly affecting the knowledge base underlying medical education. Some educators assert that the unifying scientific concepts inherent in molecular biology represent a paradigm shift to an interdisciplinary knowledge base. In addition, new teaching methods and advances in medical informatics provide tools for integrating the multiple disciplines represented in medical instruction. Examples of these concepts and approaches are provided in Chapter 3 and the appendixes with respect to integrating environmental medicine into medical education. Funding and Availability of Environmental Medicine Programs There are several programs that support education and training, curriculum development, and research in environmental medicine, although funding is limited. A brief description of these opportunities is provided here, with additional details presented in Appendix D. Appendix D also lists the medical schools that currently receive support from these programs in order to assist the reader in identifying where to find expertise in environmental medicine (see pages 917–918 and 920). Among the programs described in Appendix D are several sponsored by the National Institute of Environmental Health Sciences (NIEHS), one of the principal federal agencies for biomedical research on the effects of chemical, physical, and biological environmental agents on human health and well-being. These NIEHS sponsored programs include the Environmental/Occupational Medicine Academic Awards to medical school faculty members for improving environmental/occupational medicine curricula, and the Environmental Health Sciences Center Awards to universities for conducting multidisciplinary research in environmental health. NIEHS has established Basic Research and Education Programs to support research on preventing adverse human health effects of hazardous substances, and Hazardous Waste Worker Health and Safety Training Awards and Programs to support development and administration of programs for training workers and supervisors in health and safety. Clinical Investigator Awards are also available for the development of clinical investigators in the field of environmental health/human toxicology. Another program described in Appendix D is Project EPOCH-Envi. This project, cosponsored by the National Institute for Occupational Safety and Health (NIOSH) and the Agency for Toxic Substances and Disease Registry (ATSDR), focuses on introducing curricula in occupational and environmental medicine into primary care residency programs. ATSDR also provides a self-study series called Case Studies in Environmental Medicine (many of which appear in the Appendixes of this report). These case studies guide physicians through the diagnosis and treatment of illness related to hazardous

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Environmental Medicine: Integrating a Missing Element into Medical Education environmental exposures. They are useful teaching aids and can also be completed for continuing medical education credit. Some state and county programs, also supported by ATSDR, offer funding and assistance to health departments for developing educational materials and activities in environmental medicine for health care professionals. Other opportunities for obtaining continuing education and clinical treatment information include those that are available through the American College of Occupational and Environmental Medicine, which offers a continuing education course entitled “Core Curriculum in Environmental Medicine,” and the Association of Occupational and Environmental Clinics, which is a national network of clinical facilities with expertise in environmental and occupational medicine. Details on these and many other programs offering assistance, opportunities, and information in environmental medicine are presented in Appendix D, and we urge consultation with them. CONCLUSIONS AND RECOMMENDATIONS There is considerable agreement that the traditions of medical education need to be adapted to a rapidly evolving social, political, and environmental context, and that there is also a need for more integration of basic and clinical sciences, increased mastery of biological concepts, increased attention to the social and behavioral aspects of health and disease, and greater use of ambulatory and community clinical experiences in the learning process. Although deep structural resistance to such change is inherent in the organization of medical schools, the current climate of expectation with respect to an increased emphasis on prevention in health care, a paradigm shift in the knowledge base, and the successes of the limited numbers of programs that support the integration and enhancement of environmental medicine in medical education are favorable to progress toward these goals. Insofar as the prospect of integrating environmental medicine into the medical school curriculum constitutes a response to the calls for curriculum reform, the climate offers opportunities for taking immediate action to enhance the content of environmental medicine in both medical education and practice. In addition, continued support and expansion of programs that currently support research and training are needed to ensure the progressive enhancement of competency in environmental medicine in medical education and practice. This should build on the success of current programs and include adequate funding to support reasonable growth and progress in curriculum development, faculty development, and continuing education.