Incorporating an environmental/occupational medicine theme into the medical school curriculum

Climate change and health in international medical education - a narrative review

Objective

Climate change is a key threat to human health worldwide. Accordingly, medical education should prepare future physicians for climate-associated hazards and corresponding professional challenges. Currently, this is not yet implemented across the board. The aim of this review is to present (I) the knowledge and (II) the attitudes of medical students and physicians towards climate change and (III) the expectations of medical education as formulated by medical students. In addition, the available literature will be used to look at (IV) global teaching activities, (V) international learning goals and learning goal catalogues, and (VI) applied teaching methods and formats. This review should simplify and, considering the urgency of the topic, accelerate the design of future teaching activities.

Methodology

The paper is based on a selective literature search supplemented by a topic-guided internet search.

Results

Knowledge about the causes and concrete health consequences of climate change seems to be incomplete. The majority of medical students consider human health to be at risk from climate change and the health sector to be inadequately prepared. A majority of surveyed medical students would like to see teaching about climate change. It is evident that internationally, teaching projects on climate change and climate health, as well as topic-specific learning objectives and learning goal catalogues, have been developed and integrated into medical education.

Conclusion

There is a need for and acceptance of teaching climate change in the medical curriculum. This literature review can assist in the development and implementation of new teaching formats.

It's Time for Medical Schools to Introduce Climate Change Into Their Curricula

Climate change presents unprecedented health risks and demands universal attention to address them. Multiple intergovernmental organizations, health associations, and health professions schools have recognized the specific importance of preparing physicians to address the health impacts of climate change. However, medical school curricula have not kept pace with this urgent need for targeted training.The authors describe the rationale for inclusion of climate change in medical education and some potential pathways for incorporating this broad topic into physician training and continuing medical education. Reasons include the magnitude and reach of this transboundary issue, the shared responsibility of the U.S. health care sector as a major contributor to greenhouse gas emissions, and the disproportionate effects of climate change on vulnerable populations. The integration of climate-change-related topics with training of essential physician skills in a rapidly changing environment is feasible because many health topic areas already exist in medical school curricula in which climate change education can be incorporated. To fully integrate the health topics, underlying concepts, and the needed clinical and system-wide translations, content could be included across the scope of training and into continuing medical education and faculty development. The authors provide examples of such an approach to curricular inclusion.

Developing a Problem-Based Learning Approach to the Integration of Environmental and Occupational Health Topics into Medical School Curriculum

OBJECTIVES

A pilot study incorporating environmental and occupational health (EOH) learning objectives into medical school curriculum using problem-based learning approach.

METHODS

One hundred eight-four Case Western Reserve University medical students participated in problem-based learning curriculum emphasizing EOH topics. Multiple choice (MCQ), short essay (SEQ), and summative short essay (SSEQ) questions assessed student knowledge. Two rating scale questions and one open-ended question determined student attitudes and confidence.

RESULTS

Eighty percent of students answered 10 of 12 MCQs correctly. Students scored 70% on three of four SEQs and averaged 95.2% and 88.5% on two final SSEQs demonstrating improvement in student knowledge. Students rated the importance of and confidence in EOH topics as 4.4 and 3.9, respectively.

CONCLUSION

Problem-based learning facilitated inclusion of new EOH content in pre-clerkship curriculum leading to achievement of students' cognitive objectives, positive attitudes, and improved confidence in EOH topics.

Promoting integrated approaches to reducing health inequities among low-income workers: applying a social ecological framework

BACKGROUND

Nearly one of every three workers in the United States is low-income. Low-income populations have a lower life expectancy and greater rates of chronic diseases compared to those with higher incomes. Low- income workers face hazards in their workplaces as well as in their communities. Developing integrated public health programs that address these combined health hazards, especially the interaction of occupational and non-occupational risk factors, can promote greater health equity.

METHODS

We apply a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: the worksite, state and local health departments, community health centers, and community-based organizations.

RESULTS

Examples of successful approaches to developing integrated programs are presented in each of these settings. These examples illustrate several complementary venues for public health programs that consider the complex interplay between work-related and non work-related factors, that integrate health protection with health promotion and that are delivered at multiple levels to improve health for low-income workers.

CONCLUSIONS

Whether at the workplace or in the community, employers, workers, labor and community advocates, in partnership with public health practitioners, can deliver comprehensive and integrated health protection and health promotion programs. Recommendations for improved research, training, and coordination among health departments, health practitioners, worksites and community organizations are proposed.

Improving pediatrician knowledge about environmental triggers of asthma

BACKGROUND

Control of environmental triggers (ETs) greatly improves asthma outcomes in children. Disseminating these findings to general pediatricians has not been well established.

METHODS

After delivering a structured and standardized presentation on ET identification and control to pediatricians, we surveyed them about knowledge and practices of ET assessment and management. We analyzed matched responses for pre/post and 3- to 6-month follow-up using McNemar's χ(2) test.

RESULTS

Matched data were available for 367 participants, and 3- to 6-month follow-up data were available for 83. There was a significant posttraining increase in intention to ask about ETs and recommend ET management. After 3 to 6 months, all responses remained significantly higher than baseline, except "likely to refer to an asthma specialist."

CONCLUSION

Pediatricians reported a significant improvement in knowledge about ETs of asthma and a willingness to incorporate exposure history questions and remediation recommendations in their routine practice.

The challenge of teaching occupational medicine to medical students: the Université de Montréal experience

Nonrecognition and mismanagement of work-related diseases is often linked to inadequate medical training. However, undergraduate training in occupational medicine faces many challenges, including lack of student interest and limited curriculum time. The purpose of this article is to present an undergraduate training program developed in one medical school to ensure that all medical students acquire the basic knowledge to recognize work-related health conditions and understand the fundamental principles of workers' comprehensive care. The program involves various learning methods including case studies, small-group learning, interactive large-group teaching, field activities, and e-learning. It has resulted in improving students' attitudes and competencies in occupational medicine and requires little curriculum time.

Integrating environmental health into medical education

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.

Teaching home environmental health to resident physicians

Healthy Homes programs seek to integrate the evaluation and management of a multitude of health and safety risks in households. The education of physicians in the identification, evaluation, and management of these home health and safety issues continues to be deficient. Healthy Homes programs represent a unique opportunity to educate physicians in the home environment and stimulate ongoing, specific patient-physician discussions and more general learning about home environmental health. The Case Healthy Homes and Patients Program addresses these deficiencies in physician training while providing direct services to high-risk households. Pediatric and family practice resident physicians participate in healthy home inspections and interventions for their primary care patients and follow up on identified risks during health maintenance and acute illness visits.

Children's Environmental Health Faculty Champions Initiative: a successful model for integrating environmental health into pediatric health care

BACKGROUND

Pediatric medical and nursing education lack the environmental health content needed to properly prepare health care professionals to prevent, recognize, manage, and treat environmental exposure-related diseases. The need for improvements in health care professionals' environmental health knowledge has been expressed by leading institutions. However, few studies have evaluated the effectiveness of programs that incorporate pediatric environmental health (PEH) into curricula and practice.

OBJECTIVE

We evaluated the effectiveness of the National Environmental Education Foundation's (NEEF) Children's Environmental Health Faculty Champions Initiative, which is designed to build environmental health capacity among pediatric health care professionals.

METHODS

Twenty-eight pediatric health care professionals participated in a train-the-trainer workshop, in which they were educated to train other health care professionals in PEH and integrate identified PEH competencies into medical and nursing practice and curricula. We evaluated the program using a workshop evaluation tool, action plan, pre- and posttests, baseline and progress assessments, and telephone interviews.

RESULTS

During the 12 months following the workshop, the faculty champions' average pretest score of 52% was significantly elevated (p < 0.0001) to 65.5% on the first posttest and to 71.5% on the second posttest, showing an increase and retention of environmental health knowledge. Faculty champions trained 1,559 health care professionals in PEH, exceeding the goal of 280 health care professionals trained. Ninety percent of faculty champions reported that PEH had been integrated into the curricula at their institution.

CONCLUSION

The initiative was highly effective in achieving its goal of building environmental health capacity among health care professionals. The faculty champions model is a successful method and can be replicated in other arenas.

Incorporating environmental health into pediatric medical and nursing education

Pediatric medical and nursing education currently lacks the environmental health content necessary to appropriately prepare pediatric health care professionals to prevent, recognize, manage, and treat environmental-exposure-related disease. Leading health institutions have recognized the need for improvements in health professionals' environmental health education. Parents are seeking answers about the impact of environmental toxicants on their children. Given the biologic, psychological, and social differences between children and adults, there is a need for environmental health education specific to children. The National Environmental Education and Training Foundation, in partnership with the Children's Environmental Health Network, created two working groups, one with expertise in medical education and one with expertise in nursing education. The working groups reviewed the transition from undergraduate student to professional to assess where in those processes pediatric environmental health could be emphasized. The medical education working group recommended increasing education about children's environmental health in the medical school curricula, in residency training, and in continuing medical education. The group also recommended the expansion of fellowship training in children's environmental health. Similarly, the nursing working group recommended increasing children's environmental health content at the undergraduate, graduate, and continuing nursing education levels. Working groups also identified the key medical and nursing organizations that would be important in leveraging these changes. A concerted effort to prioritize pediatric environmental health by governmental organizations and foundations is essential in providing the resources and expertise to set policy and provide the tools for teaching pediatric environmental health to health care providers.

Environmental health education in the medical school curriculum

OBJECTIVE

To collect baseline data of environmental history-taking skills and clinical toxicology knowledge and examine the effects of a lecture on environment on students' history-taking skills.

METHODS

An anonymous survey was distributed to third-year medical students prior to an asthma lecture that strongly emphasized environmental triggers. Fourteen questions assessed students' practices and attitudes toward environmental history taking. Six multiple-choice questions assessed clinical toxicology knowledge. Histories written by students were reviewed to determine the group's actual performance before and after a lecture on environmental health.

RESULTS

Although students reported that an environmental history was important, few asked about environmental history topics other than smoking and pets. Occupational histories were included for adult patients, but few students asked about parental occupations for pediatric patients. Students recognized the correct antidotal therapy for iron and acetaminophen toxicity but were less proficient at identifying clinical features of lead and organophosphate poisoning. Student history performance, when students were considered as a group, was similar to reported performance, with the presence of pets being the only significant postlecture change in history-taking behavior (P =.01).

CONCLUSIONS

Students have a positive attitude toward the need for an environmental history, but in self-reported practice and in actual practice, they explore few major environmental history issues. Data were insufficient to prove that one lecture changed history-taking practices.

Medical students' abilities to take an occupational history: use of the WHACS mnemonic

This study examined medical students' use of the WHACS mnemonic during an occupational history objective structured clinical examination station. Students' performance on the 10 content-specific station items was calculated. Factor analysis of the items was conducted, and student demographic and academic characteristics associated with performance on the station were examined. A total of 205 students completed the station. The mean number of correct responses was 5 (SD, 1.6). Students performed well on some items and less well on others. Factor analysis supported the WHACS framework. There were no significant associations with student demographic or academic characteristics. Students were aware of the particular features of an occupational history but were deficient in other areas; this awareness was not related to demographic or academic characteristics. The WHACS mnemonic could be an effective tool to teach occupational history-taking skills.

Effectiveness of an occupational and environmental medicine curriculum as indicated by evaluation of medical student performance on an objective structured clinical examination

Medical students must learn to recognize occupational and environmental-related illness. An occupational and environmental medicine curriculum can achieve this goal. The curriculum must be evaluated to ensure that medical students are learning to recognize exposure-related health conditions and to evaluate if this ability correlates with medical interviewing skills. A case, formatted for an Objective Structured Clinical Examination (OSCE), was developed to evaluate student performance on an exposure-related clinical problem. The OSCE results were analyzed to identify the areas that differentiated the students who recognized an exposure-related medical condition from those who did not. We conclude that an OSCE is an effective curriculum evaluation tool to assess whether a core occupational and environmental-related curriculum is contributing to student learning in exposure history-taking and associated clinical reasoning skills.