Across the continuum
Integrating Environmental Health Into Medical Education

https://doi.org/10.1016/j.amepre.2011.06.007Get rights and content

Abstract

Although environmental factors contribute to more than 25% of all global disease, and toxic agents ranked fifth in underlying causes of U.S. deaths in 2000, environmental medicine education is largely omitted in the continuum of U.S. medical education. The paucity of specialists trained in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with the lack of adequate general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous substances in the environment, contributes to lost opportunities for primary prevention or early intervention to mitigate or minimize environmentally related disease burden.

Survey findings of graduating medical students over the past few years have identified environmental health as a medical school topic area that can be improved. This article reflects a panel presentation on the challenge of including environmental health in general medical education. It was given at the 2010 “Patients and Populations: Public Health in Medical Education” conference cosponsored by the CDC and the American Association of Medical Colleges. A variety of educational strategies, models, and educational resources are presented that illustrate how recommended competency-based environmental health content can be integrated into medical education to better prepare medical students and physicians without specialized expertise in environmental medicine to provide or facilitate environmental preventive or curative patient care.

Introduction

Although environmental factors contribute to more than 25% of all global disease,1, 2 and toxic agents ranked fifth in underlying causes of U.S. deaths in 2000,3 environmental medicine education is largely omitted in the continuum of U.S. medical education, leaving future physicians and current practitioners without expertise in environmental medicine to provide or facilitate environmental preventive or curative patient care. The paucity of specialists trained in environmental medicine (i.e., occupational medicine4 and other preventive medicine specialties and subspecialties5, 6, 7) coupled with the lack of adequate general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous substances in the environment contributes to lost opportunities for primary prevention or early intervention of potential environmentally related disease.

Graduating medical students consistently report receiving inadequate instruction in environmental health.8 Practicing primary care physicians report the need for environmental medicine education to better recognize, diagnose, and treat patients in their clinical practice with environmentally related illness.9, 10, 11, 12 In addition, the Liaison Committee on Medical Education (LCME) standards for medical schools in the U.S. has recently modified requirements to add “public health sciences” (which includes environmental health) to the required curriculum.13 Recommended environmental medicine competencies for graduating medical students and for practicing primary healthcare providers have been developed.14, 15, 16 Integration of environmental medicine content into existing medical school curricula early and throughout the continuum of medical education is pivotal toward addressing the environmental medicine education and clinical practice gap that exists today.

Section snippets

Human Health Impacts from Toxic Environmental Exposures

A growing body of research in adult and pediatric populations finds many established and suspected environmental exposures are linked to genetic, immune, reproductive, behavioral, and endocrine dysfunctions that lead to cancer or other adverse health effects.1, 2, 3, 17, 18, 19, 20, 21 Exposure to environmental toxic pollutants is associated with increased mortality from cancer, respiratory, and cardiovascular diseases.3, 22, 23, 24, 25 In addition, studies have estimated that 25%–33% of the

Need for Environmental Health in Medical Education

Environmental medicine has a broad scope blending the principles of epidemiology, toxicology, industrial hygiene, behavioral sciences, and environmental health within the context and practice of clinical medicine. The ultimate goal of environmental medicine is the prevention of disease and injury from acute and chronic exposures to hazardous substances in the environment.

Only a small portion of U.S. physicians have specialized, competency-based training in environmental medicine (i.e.,

Competencies for Graduating Medical Students

In response to the shortage of trained occupational and environmental medicine expertise in the U.S., the IOM recommended the integration of environmental health concepts into all levels of medical education.15, 16 The IOM developed the following competency-based recommendations for graduating medical students in environmental health:15

  • •

    understand the influence of environment and environmental agents on human health;

  • •

    elicit appropriately detailed environmental exposure history, including work

Competencies for Primary Healthcare Providers

The IOM14, 16 committee convened to define and support the role of the primary care physician in environmental and occupational medicine and recommended that at a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make appropriate referrals for follow-up. In order to carry out this standard of care, the committee recommended that physicians must:

  • •

    know some basic principles of occupational and environmental disease

Exposure–Disease Continuum Framework to Teach Environmental Health

Use of the exposure–disease continuum (Figure 1) as a conceptual framework to teach environmental health supports opportunities to weave environmental medicine into basic science courses, clerkships, and residency training. This framework depicts, in a linear fashion, how a completed exposure pathway may lead to clinical disease. Concepts of primary, secondary, and tertiary prevention, susceptibility, and key competencies in environmental medicine such as taking an appropriate environmental

Incorporating Environmental Medicine Into Existing Medical School Curriculum

Adding new material to an already packed curriculum is challenging. Most medical schools have little unscheduled time in the curriculum and often lack resources, including faculty with environmental health expertise, to teach an in-depth course in environmental health. Integrating environmental health content into existing courses may be a more feasible approach. Strategies to build faculty capacity might include distance-based education that allows sharing of faculty with expertise in

Other Preclinical Opportunities to Include Environmental Medicine

Taking an environmental exposure history is one core competency to be mastered in environmental medicine. The preclinical “Patient Care” courses, wherein the systematic method of history taking is explained, affords an opportunity to teach this.

Additionally, vulnerability to environmental insults by life stage should be emphasized. For example, medical students should learn of increased susceptibility and health risks of fetal and pediatric populations from exposure to common environmental

Opportunities to Include Environmental Medicine in Clinical Clerkship

During clinical clerkships, the environmental medical training focus can shift to case presentations on the wards, in the clinic, and in Grand Rounds. The proper method of taking the exposure history can be reinforced by gathering this information each time a history and physical are performed. When appropriate, this is also true for the postgraduate resident pursuing specialty training. Study materials including peer-reviewed case studies in environmental medicine, discussed in the next

Resources

The ATSDR, based in Atlanta, Georgia, is a federal public health agency of the DHHS and serves as one of the key federal agencies responsible for assessing health risks from environmental exposures and minimizing or preventing ill health from environmental exposures.

A part of the ATSDR's congressional mandate is to develop and distribute to the states, and on request to medical colleges, physicians, and other health professionals, educational materials on the medical surveillance, screening,

Conclusion

Exposure to environmental toxics is unavoidable in modern society. While many factors will determine whether or not one's health is adversely affected by environmental exposures, early diagnosis of environmentally related disease can be life-altering. Additionally, since signs and symptoms of environmentally related illness are often nonspecific, an increased index of suspicion in patient assessment is paramount to prevention and mitigation of environmental exposures, and diagnosis and

Acknowledgments

All support of the authors' work is derived from their affiliation with the Agency for Toxic Substances and Disease Registry.

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Agency for Toxic Substances and Disease Registry.

Publication of this article was supported by the CDC-AAMC (Association of American Medical Colleges) Cooperative Agreement number 5U36CD319276.

No financial disclosures were reported by the authors of this

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