Editor’s Note: Throughout 2015, an AAMCNews series explored how medical schools and teaching hospitals are addressing social determinants of health in their communities through research, clinical care, and education.
A physician who treats a patient’s lung problems solely as a pulmonary issue might miss important diagnostic clues. For example, does the person live or work where air quality is compromised? Doctors are not always trained to look for such factors. But some experts are calling for the medical school curricula to include more training on the health effects of the physical environment.
Environmental health has many facets that are focused broadly on the impacts on health of the natural and the “built” environments. Epidemiological data about environmental impacts on health provide important insights for physicians and researchers. At the same time, a growing body of knowledge is showing how environmental factors can have a disproportionate impact on certain populations, such as the elderly and families living in poverty.
“In the broadest sense, the environment is probably the major contributor to the determinants of health,” said Karen B. Mulloy, DO, MSCH, an associate professor at the Case Western Reserve University School of Medicine.
The typical medical school curriculum trains students to focus on the molecular origins of disease or on how organs function. But as the 2011 AAMCBehavioral and Social Science Foundations for Future Physicians observed, “Health is the product of the interactions among biology, genetics, behavior, relationships, cultures, and environments.”
An Institute of Medicine report 20 years ago framed the need for an environmental health perspective in medical practice and suggested six related learning objectives for medical students. In a study of pediatricians published in 2006, however, just one in five had received training in environmental history taking. An earlier study reported that in medical schools requiring content related to environmental medicine, students received just seven hours of such training. Nearly one-quarter of schools surveyed did not require any environmental content. And the AAMC’s 2013 survey of medical school graduates found that more than one-third of respondents said they received “inadequate” instruction in environmental health.
“In the broadest sense, the environment is probably the major contributor to the determinants of health.”
Karen B. Mulloy, DO, MSCH, associate professor at the Case Western Reserve University School of Medicine
With medical school curricula already overflowing, adding blocks of environmental health content seems unlikely. Even though students can opt to specialize in a field like occupational health or pursue a joint MD/MPH degree, some experts argue that all medical students need better grounding in environmental content. Medical educators have pinpointed several key leverage points where environmental content can be inserted into medical school training. Mulloy, for example, said the answer is not to add 10 hours of lecture, but rather to try to integrate environmental content where it makes educational sense. At Case Western, for example, environmental content often fits naturally in case-based “IQ Sessions” that meet three times per week.
Field experiences offer yet another strategy. First year medical students at Case Western complete a curricular block on population and public health that sends them to places like construction sites and clinics that serve the homeless. Traveling to where patients live and work, Mulloy said, yields important practical lessons and helps students “open their eyes to all aspects of the patient’s health.”
For Robert Harrison, MD, MPH, a clinical professor of medicine at the University of California, San Francisco, School of Medicine, a summer field experience with chemical workers while he was in medical school inspired him to design an internship program that sends students on environment-focused field practicums between their first and second years. Students study job-related health and safety problems among workers, learning and helping to identify options to improve health.
At the beginning of the year, one of Harrison’s second-year students, Zachary Wettstein, was so disappointed at the dearth of content about his own passion, climate change, that he banded with fellow students to organize an elective on environmental health and social justice. “In our generation as future doctors and health care providers, climate change is going to be the No. 1 health issue, and the curriculum needs to reflect that,” Wettstein said. Residencies provide another insertion point for environmental health content. James R. Roberts, MD, MPH, a professor of pediatrics at the Medical University of South Carolina, said that meeting with residents in conferences and clinics provides natural opportunities to introduce content related to environmental health that do not occur in the first two years of medical school. Roberts also believes that adding more board exam questions related to environmental health will help drive more related content into medical student training.
Harrison believes that faculty mentors can help students learn more about environmental health. But as Roberts observed, a key challenge is that even faculty who have a lot of expertise in environmental health lack knowledge of certain topics. Continuing medical education might be part of the solution, he suggested, but even more important is medical schools supporting faculty so they can be better attuned to environmental health and its place in medical education.
This article originally appeared in print in the February 2015 issue of the AAMC Reporter.