However, many of the interventions flow directly from an individual physician-patient encounter that identifies a health problem or risk attributable to specific environmental factors or conditions. The clinical encounter provides a unique opportunity for the clinician to practice prevention-oriented primary care. Moreover, a single diagnosed case of environmental or occupational illness often serves as a sentinel, alerting the public health community that prevention has failed, that other members of the population may be at risk, and that intervention is needed Rutstein et al.
- The Drift of Sea Ice (Springer Praxis Books).
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- Mark E. Smith and The Fall: Art, Music and Politics (Ashgate Popular and Folk Music Series)?
For many years, physicians and other health care providers have been largely uninvolved in environmental issues related to human health. Certainly, their undergraduate and graduate medical education did little to encourage or prepare them for such involvement. Indeed, the paucity of their training in this area has been well documented Institute of Medicine, ; Levy, Surveys have shown, for example, that in only 50 percent of U. By , improvement was only modest, with 66 percent of schools requiring about six hours of study in occupational and environmental health Burstein and Levy, A survey of 89 departments of internal medicine at U.
Resident training in the broader area of environmental medicine has been even less common. Moreover, a review of the curriculum catalog from the Association of American Medical Colleges indicates that courses in environmental medicine are rare and, when offered, are usually elective in nature, competing with many popular alternatives.
Definition of Environmental medicine
Medical education's focus on the individual patient with disease has not encouraged faculty and students to step beyond the medical model and consider the health of the population—be it the physician's practice population, a worker population, a neighborhood or community population, or the population of a state, region, or nation. Blame might also be placed on the many well-known deficiencies of the medical education system—a system that has compartmentalized teaching and learning into rigid disciplines, focused on information transfer instead of information management and problem solving, and rewarded research over teaching Association of American Medical Colleges, ; a.
There are other explanations for physician noninvolvement, however. Practical constraints are enormous; physicians often just do not have the time to get involved in their patients' environmental or occupational health problems, many of which are complex and time consuming.
The technical aspects of such environmental problems as air pollution, occupational disease, and toxic emissions can be daunting. Moreover, reimbursement for time spent on environmental questions is often lacking, and administrative burdens such as those imposed by worker's compensation cases may be formidable Institute of Medicine, Indeed, the realities of clinical practice reinforce the practitioner's need to focus on the individual patient with disease.
Furthermore, in the area of environmental and occupational health, the possibility of interaction with the legal system looms large in the minds of some physicians; however remote, this possibility can discourage some physicians from pursuing an environmentally related diagnosis. There may also be philosophical, political, social, and cultural explanations for lack of physician involvement. For example, it has been suggested that physicians are sometimes uncomfortable with the priorities of environmental activists Guidotti, With growing public awareness and concern about the health effects associated with environmental agents, however, physicians and other health care providers can no longer avoid involvement in environmental medicine.
In , the IOM examined the role of primary care physicians in occupational and environmental medicine and, as a result, 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 such illnesses and refer patients appropriately for follow-up Institute of Medicine, Two subsequent IOM reports on occupational and environmental medicine addressed physicians' needs for medical information Institute of Medicine, and the physician shortage in occupational and environmental medicine Institute of Medicine, Following up on the IOM's — series of reports, this committee has described a continuum of roles that physicians can assume in the area of environmental medicine see Box 3.
A Continuum of Roles. A continuum of roles illustrates several levels and types of activity for physicians in the area of environmental medicine. Physicians can: provide clinical care and advice for individual patients in an office setting the environmentally more At one end of the continuum is the role of the environmentally competent clinician. At the very minimum, this role includes the ability to identify possible environmentally related conditions to make the appropriate referrals for evaluation and follow-up care. To conduct even this limited activity, physicians will need to obtain certain knowledge and develop certain skills that are not routinely provided in U.
With this and additional training, clinical competence can be expanded to include the ability to appropriately diagnose, treat, and manage patients with environmentally related disease as well as the ability to conduct basic and clinical research and to educate and counsel patients about environmental risks. Moving beyond this clinician-educator role toward the other end of the continuum, physicians can expand into areas of increasing activism in relation to individual and public health and the environment.
The extent of an individual physician's activity in environmental medicine is, in large measure, a matter of personal preference.
However, there is little doubt that basic clinical competence in environmental medicine is essential for all physicians. As individual and community concerns about the environment grow, physicians will encounter inquisitive, confused, at-risk, and diseased patients in their offices—patients with questions, concerns, complaints, signs, and symptoms. Medical schools need to respond to society's growing environmental concerns by developing educational programs that teach clinicians how to meet these needs.
An important long-term goal in this regard would be the establishment of a network of specialists in the field to whom referrals can be made. The Association of Occupational and Environmental Clinics see Appendix D provides a good example of a national network of clinical facilities dedicated to research and education as well as to the prevention and treatment of occupational and environmental diseases. The committee was given six specific tasks:. The committee convened a public workshop in May to help begin the process, and issued an interim report in the fall of that recommended establishing six competency-based learning objectives, on which the present report builds.
Although the committee's charge was to focus on undergraduate medical education, it was difficult for the committee to conceive of accomplishing its objectives solely within those confines. The context of the continuum of undergraduate and graduate medical education seemed more appropriate because environmental medicine permeates the entire spectrum of medical practice and should similarly reach throughout the continuum of medical training. Some of the discussion in this report therefore refers to residency training and continuing medical education. The chapters and appendixes that follow reflect the committee's further pursuit of its six tasks.
The report articulates a general program of implementation strategies and provides immediate practical advice to individual educators, students, and practitioners who either are interested in integrating more environmental medicine content into medical education or need resource information to help them address clinical situations. Chapter 2 begins by laying the foundation for an environmental medicine curriculum centered on six competency-based learning objectives. Chapter 3 then uses these objectives as a framework for identifying likely access points in the curriculum for integrating environmental medicine into today's medical studies.
Chapter 4 addresses both the barriers to implementing such a curriculum and the opportunities for reducing these barriers. Chapter 5 presents concluding remarks that summarize some of the events that led to this report and the committee's optimism with respect to the ease with which medical education can incorporate an enhancement of the training of environmental medicine. Recommendations for integrating an enhanced program of environmental medicine throughout our system of medical education and practice appear at the ends of the individual chapters i.
To enhance the report's practical value, four appendixes are included that provide detailed information on available educational resources and teaching aids. They can be used to facilitate the integration of environmental medicine into both education and practice.
It also identifies case studies from Appendix C that could be used in these courses or contexts. This appendix has four indexes to help the reader determine the most relevant cases for a particular course, clerkship, or other purpose. It is our hope that these materials and resources will facilitate the integration and enhancement of environmental medicine in medical education. Turn recording back on. For more than 30 years, the Duke Division of Occupational and Environmental Medicine OEM has been committed to improving the health of working populations. Duke OEM offers a variety of services including clinical evaluations, corporate consulting, toxicological assessments, and injury prevention.
As one of the top academic OEM groups in the country, the division is also dedicated to training physicians through its residency program. Residents are trained to serve as leaders in academia, public health, the military, and corporations. Duke OEM offers a variety of ergonomics consulting services, including work site evaluations, risk assessments, facility design, and professional training courses related to ergonomics. These courses focus on office ergonomics, supervisor and manager training, manual materials handling and reducing injuries in the health care environment.
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