The ideological battle between nurture and nature aside, an unhealthy environment generally evokes greater rates of morbidity, mortality, and disability in a population. Given that, it would seem to follow that environmental medicine would be among the dominant forces in the world of medicine. But in practice, environmental medicine boasts only a small following in the international medical community. Not surprisingly, the training of primary care physicians in occupational and environmental medicine has traditionally been inadequate at every level of medical education. Yet the prognosis for environmental medicine isn't entirely grim: in recent years, improvements have been made and the trend is toward continuing to expand the field of environmental medicine.
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Photo Credit: The George Washington University |
"Public health and preventive medicine has been a neglected wing of medicine in the U.S. and environmental and occupational medicine has been a part of that wing," observes Rosemary Sokas, associate professor of medicine and health care sciences at George Washington University in Washington, D.C. As a result, fewer resources have historically been dedicated to environmental medicine, and its knowledge base has been left wanting--not only in the research arena but among individual doctors and the public as well. "The tragedy is that traditional medicine has given environmental medicine the back seat--partly due to money and partly status," Sokas says.
The historic disregard of environmental medicine is bumping up against the modern realization that primary care physicians are the main protection citizens have against environmental illness and effects. "There isn't too much else out there," says James P. Keogh, associate director of the Occupational Health Project at the University of Maryland Medical School.
The picture isn't looking any brighter in terms of what type of environmental hazards people will be exposed to in the future either. "Communities will be in greater jeopardy. . . . As community standards go down, the health of the community will, too," says Annette Kirshner, a program administrator in the Division of Extramural Research and Training at the NIEHS.
Defining the Field
A leading obstacle to the acceptance of environmental medicine by the mainstream medical community has been the ambiguity and mutability of its definition. While most people instantly know what a cardiologist or a radiologist is, even some in the health care business are often confused by the term environmental physician.
Different experts describe varying components when attempting to define environmental medicine. "Traditional medicine has been very disease oriented. Environmental medicine really requires a slightly different focus--though it's a more nebulous focus--and it also requires taking a different history [of the patient]," explains Kirshner. Yet another school of thought believes the field encompasses a more global definition, whose parameters only seem to expand with the research's knowledge base. Scientists and doctors in this group would include everything from health effects experienced from exercising on a day when air pollution is particularly bad, to the symptoms described as Gulf War syndrome, to the relation of climate change to malaria in the bailiwick of environmental medicine.
"Some people get kind of manic about it, but I kind of like thinking about it [in a global way]," says Sokas. Many doctors who are specialists in other fields actually practice environmental medicine on a daily basis, says Sokas, citing tropical medicine or infectious disease experts as examples. Accordingly, she says, such overlapping specialties should be included when inventorying environmental medicine.
A committee of the National Academy of Sciences' Institute of Medicine came up with a working definition--which acknowledges environmental medicine's broad parameters--in a 1995 report on the subject titled Environmental Medicine: Integrating a Missing Element into Medical Education. "Environmental medicine refers to diagnosing and caring for people exposed to chemical and physical hazards in their homes, communities, and workplaces through such media as contaminated soil, water, and air," the report states. The definition excludes diseases caused by lifestyle factors such as tobacco and alcohol use and diet, as well as environmental conditions such as violence.
Clearly, there is dissension within the medical and scientific community as to what environmental medicine embraces. And in practice, what is considered environmental medicine usually depends on the physician. Generally speaking, however, environmental medicine refers to the prevention and treatment of diseases related to the environment, as opposed to occupational medicine which is concerned with the prevention and treatment of work-related injuries and illnesses. But even this distinction is blurred. Many people still tend to confuse the two specialties or view them as "merged at the hip," as Sokas puts it, because environmental medicine got its start in occupational medicine departments at many medical schools. In addition, environmental medicine's traditional origins in occupational medicine "have given it a slightly litigious quality," Kirshner says, that may detract from its credibility.
Another twist in the evolution of the field is that contemporary society itself is blurring the lines between home and office, further clouding the distinction between occupational and environmental medicine. For example, some people bring their children into the workplace, while others work at home. Meanwhile, most departments of occupational medicine have been changing their names to environmental and occupational medicine in recognition of the broader context that is evolving. Just the same, the NIEHS's Kirshner says "we view occupational medicine as a subset of environmental medicine."
Currently, occupational medicine is the only specialty of the two that is recognized by the American Board of Specialties. A physician can be board-certified in preventive medicine in one of three categories: occupational medicine, public health and general preventive medicine, and aerospace medicine. In the next year, medical management may be added to this list. Also, there is talk of changing the occupational medicine specialty to "environmental and occupational medicine," but a formal push has not been launched with the board.
Second Class Citizenship
No matter how they define it, most experts agree that environmental medicine has not been awarded the respect it deserves in the medical community. A 1991 survey of more than 100 medical schools published in the American Journal of Public Health found that, for the most part, occupational and environmental health issues continue to be overlooked by most medical schools. According to a 1994 report in the American Journal of Public Health of a 1991 survey, about 68% of schools teach environmental and occupational medicine with an average of six hours of the curriculum being spent on environmental and occupational health. And these numbers are an improvement. A similar survey in 1977, reported in the same journal article, found that only half of U.S. medical schools taught occupational and environmental health and when they did, spent an average of only four hours on the unit.
The way the medical system is structured has also been a stumbling block in the evolution of environmental medicine. Medical school curricula are crowded and their departmental structures tend to be very hierarchical and highly competitive. "So much depends on the public health sector, but for medical centers [environmental medicine] has traditionally not been a moneymaker and has suffered from the fact that it can't pay its own way," explains Kirshner. The effect of this attitude among the medical profession has been that environmental medicine is viewed as far less glamorous than other specialties. Sokas notes, "People don't make TV shows about environmental physicians, they make them about ER doctors."
In addition, doctors generally get promoted in a discipline on the basis of how specialized and focused their practice is, and greater focus typically brings more publicity and more grant money. "That's the scientific model. You don't get points for being interdisciplinary," says Sokas.
Practice
One obstacle to the advancement of environmental medicine has been the frustrations physician encounter when trying to practice it clinically. First, research in environmental medicine lags far behind other more traditional medical specialties. In environmental medicine, Sokas explains, researchers are still figuring out what the questions are. Thus, the level of uncertainty that environmental physicians must work with can be far greater than for more established areas of medicine. Second, resources available to environmental physicians to help them understand the complex interactions of factors such as video display terminals (VDTs), toxic emissions, and genetics in human systems are often lacking. Third, physicians are usually reluctant to become involved in the bureaucracy of worker's compensation cases, debates between environmentalists and industry, or the legal ramifications that may accompany a diagnosis of an adverse environmental health effect. "Often when contamination occurs in a community, physicians back off," Sokas says.
In short, Sokas says, "Training is very important, but beyond training the way people practice medicine has to include population-based information and also have the research to back it up."
Industry Influences
Since the early days of occupational and environmental medicine, industry has been a key player in how these disciplines have evolved and are perceived. Traditionally, occupational physicians employed by industry have generally practiced in a health care setting. But in the past decade, in light of regulations, liability, and mounting health care costs, the business world has shifted its emphasis beyond the traditional clinical settings to in-house assessment of the ramifications of its operations. In fact, strategic guidance in regulatory areas has become increasingly necessary for businesses to stay competitive. The chemical industry, for one, has been at the forefront of addressing this need.
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Photo Credit: Elizabeth Gresch |
"Environmental medicine was really noticed by the business world about five years ago," says Elizabeth E. Gresch, currently an occupational physician consultant for General Motors. The change, she says, is due partly to media attention, partly to lawsuits, and partly to the reality that American businesses have to compete with countries where the wages are one-tenth of those in the United States.
"Businesses are generally concentrated inward on making a profit," says Gresch, a past president of the American College of Occupational and Environmental Medicine. Companies simply haven't had the resources in the past to address many of these concerns, according to Gresch, who has worked for Dow Chemical and other large companies. Moreover, Gresch says the challenges of occupational medicine are not limited to the United States. "It's a worldwide issue," Gresch says.
In the near future, most experts predict the need for environmental medicine consultants will increase as consciousness about the effects of work on health, law suits, and government rules and regulations increase. About one-third of environmental and occupational medicine residents were planning to look to industry for employment immediately after finishing training, according to the 1991 survey reported in the May 1994 issue of the American Journal of Public Health. However, over the long haul, about 40% said they would prefer consulting positions like those enjoyed by Stephen Dawkins, owner of Occupational Health International in Atlanta (which consults to Coca-Cola and the Cable News Network) and Richard Cohen, who oversees the health and safety of workers at Varian Associates Inc., a manufacturer of equipment and systems for communications in the scientific, medical, and industrial markets, in Palo Alto, California. Gresch predicts that environmental medicine will play an even larger role in business in the future.
Regardless of impending budget cuts, the federal government will continue to be a large employer of environmental physicians in the future. Experts say that some of the leading career opportunities in this area will continue to be found in the federal sector at agencies such as the Centers for Disease Control and Prevention, the Department of Energy, the Environmental Protection Agency, and the Food and Drug Administration. There is also room for environmental physicians in science-oriented professional associations and environmental organizations like the World Watch Institute or the Canadian-based MotherRisk Program.
Training
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Photo Credit: NIEHS |
A major reason for the lack of environmental physicians, some experts charge, is due to a fundamental problem in the way that medical schools train doctors. On the whole, the medical profession has been "abysmally ignorant" about environmental medicine, Kirshner says. Keogh says that often physicians will treat symptoms without a real handle on what the cause of an illness is. Moreover, says Sokas, "The focus [of training] is too heavily on treatment and not prevention, and when it does focus on prevention it focuses only on the patient in front of [a physician]." Sokas argues that medical students need to learn to look at both individual patients and larger groups of potential patients "Not many students take a population view of health care," she says.
Experts from all walks seem to agree that changing the way physicians are trained is the best way to ensure the future of environmental medicine. While past attempts to reform medical curricula have largely been hindered by entrenched opposition to change within the medical establishment, a push is on to change not only the content but also the structure of medical education. And many medical educators are looking to incorporating environmental medicine in the medical school curriculum as a part of future reforms.
An ongoing study by the Institute of Medicine is assessing how to change environmental medicine education, among other things. David P. Rall, chairperson of the IOM Committee on Curriculum Development in Environmental Medicine, writes in the 1995 IOM report, "The committee is confident that integrating environmental medicine into medical education will substantially enhance the competence of tomorrow's physicians in addressing the growing environmental health concerns of their patients and communities."
In an effort to keep up, many medical schools are working to incorporate some sort of training in environmental health into their curricula. Rather than segmenting out new blocks or courses in an already crowded and often territorial curriculum, a concerted effort is being made to integrate environmental medicine into current courses, internships, and other areas, according to the IOM report. This approach is in keeping with the idea that environmental medicine is a continuum that extends across the gamut of medical practice.
In the past year, about 180 occupational and environmental medicine residents were enrolled in the 40 accredited occupational and environmental medicine residencies in the United States and Canada. In a recent survey of these residents published in the Journal of Occupational and Environmental Medicine, the majority of residents opted to go into this type of training after they had already begun working professionally. In fact, only 11% made up their minds to pursue an occupational and environmental medicine residency before or during medical school. The survey also found that found that only 16% learned about occupational and environmental medicine in medical school and 11% were first exposed to the specialty during residency training.
In its 1995 report, the IOM committee recommends that graduating medical students have the following basic competencies in environmental medicine: they should understand the influences of the environment and its agents on human health on the basis of knowledge of relevant epidemiological, toxicological, and exposure factors; they should be able to recognize the signs, symptoms, diseases, and sources of exposure relating to common environmental agents and conditions; they should be able to elicit appropriately detailed environmental exposure history, including a work history from all patients; they 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; they 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; and they should be able to understand the ethical and legal responsibilities of seeing patients with environmental and occupational health problems or concerns.
A variety of groups are interested in broadening the role of environmental medicine in medical education, and "ours is one of them," says Kirshner, who considers the programs supported by the NIEHS to be some of the most progressive approaches to altering medical school curricula. In 1990, the NIEHS launched a grant program to help schools develop their curricula to incorporate environmental and occupational health. Currently 17 medical schools have been granted five-year Environmental Occupational Medical Academic Awards, which range from $92,000 to $188,000 a year. The University of Maryland, George Washington University School of Medicine, Yale University School of Medicine, Mount Sinai School of Medicine, Harvard Medical School, and the University of Rochester School of Medicine are among the recipients.
Although they have the common goal of integration, exactly how the programs are set up to accomplish this is left to the individual medical schools. The NIEHS hopes that the environmental medicine elements of the curricula will continue even after the grants run out.
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Photo Credit: University of Maryland |
Keogh says his goal at the University of Maryland is to educate physicians in environmental medicine "enough to play a positive role in the community." Sokas agrees, noting that primary care physicians need to be able to recognize an environmental problem in an exposure case. "If they don't have the information on hand, they need to know what type of problem they could be looking at. They don't have to learn everything--just know when they don't know."
The NIEHS also makes Environmental Health Sciences Center Awards to schools to conduct interdisciplinary research in environmental health, has set up Basic Research and Education Programs to fund research on the prevention of adverse health effects from hazardous substances, and has established Hazardous Waste Worker Health and Safety Training Awards and Programs to develop training programs for health and safety workers and supervisors.
But there are other types of programs that also accomplish some of these same goals, Kirshner acknowledges. Many schools that did not receive NIEHS funds are working to expand medical students'exposure to environmental medicine. The ATSDR and NIOSH have joined forces to set up a project called EPOCH-Envi, which works to introduce occupational and environmental medicine curricula into primary care residency programs. In addition, the ATSDR offers a self-study series: Case Studies in Environmental Medicine, and supports state and county programs that help health departments develop environmental medicine educational materials and activities for health care professionals. The American College of Occupational and Environmental Medicine also offers continuing education.
For the most part, the field of environmental medicine is being led by doctors who chose it as a second career or who received training after completing their medical degrees. More and more programs are cropping up around the nation to make this possible.
One of the more innovative programs is located in the Medical College of Wisconsin, which allows doctors to earn a master's degree in public health by computer. The program, which began enrolling students in 1986, now has 500 active students and has graduated about 165 to date, according to William Greaves, director of the Master of Public Health Programs in the Department of Preventive Medicine at the Medical College of Wisconsin in Milwaukee, who was instrumental in getting the program off the ground.
"The program was started to meet the needs of physicians to become more competent in environmental medicine while continuing to work full-time as a physician," Greaves says. All a doctor needs is a computer and a modem to enroll, so he or she doesn't have to quit practicing and lose his or her income while retraining. Students go to Milwaukee about once a year for testing.
"Compared to quitting practice it is cheap," observes Gresch. Wisconsin enrolls 50 licensed physicians three times a year on a first come-first served basis in the program. The tuition costs about $14,400 for the ten-course program, which on average takes three years to complete, though a couple of students have finished in a year's time, Greaves says. Wisconsin's program is the first long-distance education concept applied to environmental medicine that has no formal classes. A similar program is in the works at Duke University.
Long-distance commuting programs have also been successful. A prime example is the "On the Job-On Campus" program at the University of Michigan's Medical School in Ann Arbor. The two-year program allows physicians to keep their jobs while studying environmental medicine during weekend courses.
Bright Future
By all indications, experts from many interested sectors--industry, academia, government, private practice--agree that better training at all levels, while not a panacea, is an excellent starting point for pushing environmental medicine into the next century. And indeed progress has been seen in recent years.
"The situation is changing," Kirshner says. Just 30 years ago, most Americans gave little thought to the environment. But in recent years, the environment has become a key health issue in some parts of the country. Signs are indicating that the limits which once defined occupational medicine and more recently environmental medicine are continuing to expand to include increasingly interdisciplinary areas of science and medicine that may come to include everything from global change to the psychological impact of the environment. Says Sokas, someday physicians may even come to more widely recognize that the environment can be a healing place.
Julie Wakefield
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Last Update: May 7, 1997
