The teaching of occupational health in US medical schools: little improvement in 9 years

The Ontario Workplace Health Champions Program

To increase the presence of occupational medicine in the medical school curriculum in Ontario, Canada, the Ontario Workplace Health Champions Program was established 24 years ago. The Program supports a Workplace Health Champion in each medical school who ensures there is occupational medicine content in their medical school curricula. The program has expanded to postgraduate training programs, with a focus on primary care. There has been an increase in occupational medicine content in medical schools in Ontario.

Ethical thinking in occupational and environmental medicine: Commentaries from the Selikoff Fund for Occupational and Environmental Cancer Research

A tribute to Dr. Irving J. Selikoff MD, the founder of this journal, is indeed welcome now more than two decades after his passing. He was known during his lifetime as the US Father of Environmental Medicine which at the time encompassed occupational medicine and much more as industry also polluted the general environment. The 1970s were a busy time as OSHA and the EPA were newly formed and high exposures to workers were no exception. Dr. Selikoff was a brave pioneer examining workers throughout the country and Canada, publicizing their exposures, and writing and presenting the scientific results. Industry was not always receptive and controlled an astounding amount of narrative, with the creation of the American Journal of Industrial Medicine filling a void of scientific need. We four authors write about the ethics of occupational health, the plight of nuclear energy workers, the climate crisis and opportunity for unions to engage workers, and the global march toward educating medical students on workers' health and safety. All four of us interacted with Dr. Selikoff during his tenure at Mount Sinai, and over the years joined each other in promoting his legacy. Toward that end we have written articles honoring his memory.

Outcomes of a Survey-Based Approach to Determine Factors Contributing to the Shortage of Occupational Medicine Physicians in the United States

CONTEXT

There is a long-standing shortage of formally trained Occupational & Environmental Medicine (OEM) physicians despite OEM practitioners experiencing high satisfaction and low burnout.

OBJECTIVE

To explore the root causes of this shortage and suggest potential remedies.

METHODS

Cross-sectional surveys were administered to medical students queried regarding OEM training, practicing OEM physicians queried regarding timing of specialty choice, and OEM Train-in-Place (TIP) program graduates queried regarding satisfaction with training.

RESULTS

Of 247 medical student respondents, 70% had heard of OEM, 60% through one lecture. Of the 160 OEM physicians, 17% first became aware of OEM as medical students, and most would have chosen a different path had they heard sooner. Most TIP program trainees reported that they would not have undertaken specialty training without a TIP program (89%).

CONCLUSIONS

Strategies to introduce OEM earlier in medical education and TIP programs for mid-career physicians may help overcome persistent shortages of OEM specialists.

The exposome in the community

The exposome is a complicated scientific research topic but an easily understandable concept for health. By integrating multiple external forces that act upon us, it is possible to take a holistic view of our health. The exposome model provides a way to organize and integrate the many new challenges we face in our day-to-day lives. This chapter provides examples of how the exposome can be incorporated into the lives of our families, communities, and countries, including educating the public across multiple sectors. The reader will find simple and scientifically sound recommendations for reducing chemical exposures and improving one’s exposome. Since one’s genome is relatively fixed, an improvement in one’s exposome will undoubtedly lead to an improvement in one’s health.

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program

BACKGROUND

Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees.

OBJECTIVE

Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees.

METHODS

Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors.

RESULTS

Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences.

CONCLUSIONS

The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Physicians' opinions about the causes of underreporting of occupational diseases

Occupational diseases cause an important burden on health and economy; however, they are substantially underestimated. We aimed to investigate the opinions of physicians about causes of underreporting of occupational diseases. We collected data with a questionnaire, listing 30 possible causes for underreporting of occupational diseases. 478 physicians participated in the study. The first 3 most frequent causes perceived as "very important" are; employers' perception of occupational safety and health services as a loss of revenue (64.9%), prevalent employment without a legal contract (64.6%), and prevalent employment as subcontracted (59.4%). 52.1% of the physicians worked or currently working as an occupational physician. With the increase of working year as an occupational physician, there was a statistically significant decrease in the strength of importance for 17 of the 30 statements. This finding may be one of the important causes of underreporting of occupational diseases.

A Framework for Integrating Environmental and Occupational Health and Primary Care in a Postdisaster Context

CONTEXT

Integration of environmental and occupational health (EOH) into primary care settings is a critical step to addressing the EOH concerns of a community, particularly in a postdisaster context. Several barriers to EOH integration exist at the physician, patient, and health care system levels.

PROGRAM

This article presents a framework for improving the health system's capacity to address EOH after the Deepwater Horizon oil spill and illustrates its application in the Environmental and Occupational Health Education and Referral (EOHER) program. This program worked with 11 Federally Qualified Health Center systems in the Gulf Coast region to try to address the EOH concerns of community members and to assist primary care providers to better understand the impact of EOH factors on their patients' health.

IMPLEMENTATION

The framework uses a 3-pronged approach to (1) foster coordination between primary care and EOH facilities through a referral network and peer consultations, (2) increase physician capacity in EOH issues through continuing education and training, and (3) conduct outreach to community members about EOH issues.

EVALUATION

The EOHER program highlighted the importance of building strong partnerships with community members and other relevant organizations, as well as high organizational capacity and effective leadership to enable EOH integration into primary care settings. Physicians in the EOHER program were constrained in their ability to engage with EOH issues due to competing patient needs and time constraints, indicating the need to improve physicians' ability to assess which patients are at high risk for EOH exposures and to efficiently take environmental and occupational histories.

DISCUSSION

This article highlights the importance of addressing EOH barriers at multiple levels and provides a model that can be applied to promote community health, particularly in the context of future natural or technological disasters.

Barriers to use of workers' compensation for patient care at Massachusetts community health centers

OBJECTIVES

To examine barriers community health centers (CHCs) face in using workers' compensation insurance (WC).

DATA SOURCES/STUDY SETTING

Leadership of CHCs in Massachusetts.

STUDY DESIGN

We used purposeful snowball sampling of CHC leaders for in-depth exploration of reimbursement policies and practices, experiences with WC, and decisions about using WC. We quantified the prevalence of perceived barriers to using WC through a mail survey of all CHCs in Massachusetts.

DATA COLLECTION/EXTRACTION METHODS

Emergent coding was used to elaborate themes and processes related to use of WC. Numbers and percentages of survey responses were calculated.

PRINCIPAL FINDINGS

Few CHCs formally discourage use of WC, but underutilization emerged as a major issue: "We see an awful lot of work-related injury, and I would say that most of it doesn't go through workers' comp." Barriers include lack of familiarity with WC, uncertainty about work-relatedness, and reliance on patients to identify work-relatedness of their conditions. Reimbursement delays and denials lead patients and CHCs to absorb costs of services.

CONCLUSION

Follow-up studies should fully characterize barriers to CHC use of WC and experiences in other states to guide system changes in CHCs and WC agencies. Education should target CHC staff and workers about WC.

Evaluation of occupational health teaching sessions for final year medical students

Objectives

The study was conducted with the aim of evaluating applied occupational health teaching for final-year medical students at Hacettepe University, Faculty of Medicine.

Methods

The study included all sixth grade medical students (n=293) during one academic year. Pre- and post-training tests were used to assess the magnitude of change in knowledge and attitude of students on occupational health, whereas the opinion of students on several aspects of the quality of teaching sessions were assessed by using post-training questionnaires.

Results

Post-training tests revealed that the level of knowledge on all aspects of occupational health increased among medical students. An evaluation of the teaching sessions showed favorable results for the overall quality of the sessions: 81.3% of the students stated that the sessions were well organized, 81.7% remarked the workplace/factory visit was a valuable experience, and 91.0% stated feeling more competent on occupational health issues.

Conclusion

There was a greater increase in students' knowledge on technical precautions than their knowledge on issues related to medical practice in the workplace. Visiting a workplace was found to contribute to the overall aim of knowledge and attitude change on occupational health issues. The scope of undergraduate medical education should be extended by improving occupational health education with respect to educational content, duration, and methods.

Engaging medical students in occupational and environmental medicine--a new approach

BACKGROUND

For a number of reasons, engaging the interest of medical students in the discipline of occupational and environmental medicine (OEM) can be challenging.

AIMS

To renew a curriculum in OEM within a graduate medical programme with an emphasis on student involvement to maximize their interest in the topic.

METHODS

A second year student cohort of a 4 year graduate medical programme was surveyed as to their preferences for the content of a short course of OEM embedded in their medical course. The course was extensively rewritten as a result of the student survey, with a number of topics deleted from the old course and new topics added. In order to validate the content of the new course, local occupational physicians (OPs) were also surveyed as to their opinion of an appropriate curriculum in OEM for medical students. The new course was taught to the subsequent cohort of second year medical students. The students' ratings of the course pre- and post-revision were compared.

RESULTS

The student satisfaction rates of the course significantly improved as a result of the changes. The content of the student-led curriculum was strikingly similar to the course proposed by the local OP with a few key exceptions.

CONCLUSIONS

Student involvement in curriculum design in OEM is entirely feasible. It can result in a curriculum similar to that designed by expert opinion but has the advantage of strongly engaging student interest.

Practice Patterns of Pulmonologists and Family Physicians for Occupational Asthma

BACKGROUND

The longer the duration of symptoms of occupational asthma (OA) before diagnosis, the poorer the outcome. Physicians can play a key role in the early recognition of occupational lung diseases (OLDs), including OA. Our objective was to document and compare the practice patterns, barriers, and needs for early diagnosis of OA among pulmonologists and family physicians.

METHODS

Based on information from the literature and interviews with pulmonologists and family physicians, a survey was developed to obtain information on practice patterns. The survey was sent to all pulmonologists and a random sample of 600 family physicians in Ontario.

RESULTS

Eight percent of pulmonologists and 7% of family physicians report seeing >20 patients a year with OLD. The majority report taking a workplace exposure history. The most commonly stated barrier to obtaining a workplace exposure history was time constraints. Main reasons for referral to specialists for diagnosis include personal lack of expertise, testing facilities, and knowledge about workers' compensation, while lack of timely access to specialists is a barrier for referral. While most physicians identified a need for further education, those who did not identify a need for further occupational respiratory education cited low volume of patients, access to specialists, and time constraints as reasons for not wanting further education.

CONCLUSIONS

Opportunities are identified to improve health services delivery and educational initiatives for OA, with approaches tailored to each particular physician group.

The ambulatory pediatric association fellowship in pediatric environmental health: a 5-year assessment

BACKGROUND

Evidence is mounting that environmental exposures contribute to causation of disease in children. Yet few pediatricians are trained to diagnose, treat, or prevent disease of environmental origin.

OBJECTIVES

To develop a cadre of future leaders in pediatric environmental health (PEH), the Ambulatory Pediatric Association (APA) launched a new 3-year fellowship in 2001-the world's first formal training program in PEH. Sites were established at Boston Children's Hospital, Mount Sinai School of Medicine, George Washington University, University of Cincinnati, and University of Washington. Fellows are trained in epidemiology, biostatistics, toxicology, risk assessment, and preventive medicine. They gain clinical experience in environmental pediatrics and mentored training in clinical research, policy development, and evidence-based advocacy. Thirteen fellows have graduated. Two sites have secured follow-on federal funding to enable them to continue PEH training.

DISCUSSION

To assess objectively the program's success in preparing fellows for leadership careers in PEH, we conducted a mailed survey in 2006 with follow-up in 2007.

CONCLUSIONS

Fifteen (88%) of 17 fellows and graduates participated; program directors provided information on the remaining two. Nine graduates are pursuing full-time academic careers, and two have leadership positions in governmental and environmental organizations. Ten have published one or more first-authored papers. Seven graduates are principal investigators on federal or foundation grants. The strongest predictors of academic success are remaining affiliated with the fellowship training site and devoting < 20% of fellowship time to clinical practice.

CONCLUSION

The APA fellowship program is proving successful in preparing pediatricians for leadership careers in PEH.

Dermatologist and family practitioner practice patterns for occupational contact dermatitis

Medical practitioners have a role in the recognition of occupational contact dermatitis. The longer the duration of symptoms before diagnosis, the poorer the outcome. Our objective was to understand practice patterns, barriers and needs for early diagnosis of occupational contact dermatitis. A survey to obtain information on practice patterns was developed based on the literature and interviews with dermatologists and family practitioners. The survey was sent to all dermatologists and a random sample of 600 family practitioners in Ontario. Fifty-seven per cent of dermatologists and 9% of family practitioners report seeing more than 20 patients per year with occupational contact dermatitis. The majority of practitioners report taking a workplace exposure history. Barriers to taking a workplace exposure history include time constraints and lack of knowledge. Reasons for referral to specialists include a lack of expertise, testing facilities and knowledge about workers' compensation, time constraints and inadequate reimbursement, whereas lack of access to specialists is a barrier for referral. Although most practitioners identify a need for further education, a low volume of patients and time constraints are key barriers to continuing education. Opportunities are identified to improve educational initiatives and health services delivery for occupational contact dermatitis, tailored to each practitioner group.

Training Pathways for Occupational Medicine

OBJECTIVE

Consider the funding, organization, and applicant pool for occupational medicine residency training positions concerns in the United States.

METHODS

Postgraduate training models are compared for responsiveness to competence and workforce needs, including traditional residency, nontraditional residency, postdoctoral fellowship, extended courses, multiple certificate preparation, continuing medical education, "executive MPH," and implicit education (learning from consultants in the course of practice).

RESULTS

Educational models differ in comprehensiveness, crossdisciplinary experience, socialization to core professional values, financial requirements, accessibility to physicians currently in practice, potential number of trainees, and short- and long-term impact on training outcomes.

CONCLUSION

There are tradeoffs between the benefits of comprehensive program standards and the benefit of facilitated training access by reducing barriers or requirements. Recognizing and understanding assumptions about training in our discipline may inform future choices.

Undergraduate training in occupational health at Kocaeli University Medical School: a Turkish experience

Processes and conditions of production may produce unhealthy effects. Both must therefore be included in the education of health care personnel. Vocational training in occupational health at Kocaeli University Medical School, Turkey aims to demonstrate students that occupational health is a specific and important area of work within the context of primary health care. This research is a cross-sectional study. It was planned as a three stage study: 1- reviewing literature and grouping of countries according to their occupational health curricula; 2- reviewing the occupational health programs of medical schools in Turkey, and 3- recommendations for an occupational health curriculum to include an occupational health vocational training period of one week in the two month public health education program for medical interns. During this experience, senior students would be assigned to workplace health units. Of 283 medical schools found on the web, with occupational health teaching, only 20 have a curriculum that includes training in workplace health care units. In Turkey, there is no structured practical education on occupational health. In the third part of this study, we initiated at Kocaeli University School of Medicine's curriculum, a new occupational health education model applied in the workplace health units of factories. Practical experience of occupational health in the workplace is useful in introducing the community-based approach to occupational health in undergraduate medical education and understanding the determinants of health in industry.

Occupational medical history taking: how are today's physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major US teaching center

Occupational illness plays a prominent role in the health of society, yet physicians frequently neglect occupational history-taking both in clinical practice and in medical education. This study sought to examine the trends as well as related factors that influence the taking of occupationally related histories. A total of 2050 charts were reviewed for occupational information as well as several patient demographics. Physicians obtained gender and age histories in approximately 99% of their patients; however; they only completed an occupational history in 27.8%. Characteristics such as smoking, male gender, family cancer history, middle age, and medical (vs. surgical) admission were all correlated with obtaining an occupational history. Physicians continue to do a poor job of occupational history-taking and medical education must correct the situation.

Can environmental purchasing reduce mercury in U.S. health care?

Environmental purchasing represents an innovative approach to mercury control for the health care sector in the United States. The U.S. health care sector creates significant environmental impacts, including the release of toxic substances such as mercury. Our goal in this study was to provide the health care industry with a method of identifying the environmental impacts associated with the products they use. The Health Care Environmental Purchasing Tool (HCEPT) was developed and tested at nine health care facilities in the Great Lakes region of the United States. As a result, more than 1 kg of mercury was removed from four facilities. The complexity of the supply chain inhibits a direct environmental information exchange between health-care decision makers and suppliers. However, a dialogue is starting within the health care supply chain to address environmental issues. The HCEPT has been shown to assist health care facilities with that dialogue by identifying products that have environmental consequences. This promising tool is now available for further experimentation and modification, to facilitate overall environmental improvement, and to provide a systematic method for environmental assessment of health care products.

Occupational injury and illness surveillance: conceptual filters explain underreporting

Occupational health surveillance data are key to effective intervention. However, the US Bureau of Labor Statistics survey significantly underestimates the incidence of work-related injuries and illnesses. Researchers supplement these statistics with data from other systems not designed for surveillance. The authors apply the filter model of Webb et al. to underreporting by the Bureau of Labor Statistics, workers' compensation wage-replacement documents, physician reporting systems, and medical records of treatment charged to workers' compensation. Mechanisms are described for the loss of cases at successive steps of documentation. Empirical findings indicate that workers repeatedly risk adverse consequences for attempting to complete these steps, while systems for ensuring their completion are weak or absent.

The environmental history in pediatric practice: a study of pediatricians' attitudes, beliefs, and practices

We conducted a mail survey of practicing pediatricians in Georgia to assess their knowledge, attitudes, and behaviors regarding recording patients' environmental histories. Of 477 eligible pediatricians, 266 (55.8%) responded. Fewer than one in five reported having received training in environmental history-taking. Pediatricians reported that they strongly believe in the importance of environmental exposures in children's health, and 53.5% of respondents reported experience with a patient who was seriously affected by an environmental exposure. Pediatricians agreed moderately strongly that environmental history-taking is useful in identifying potentially hazardous exposures and in helping prevent these exposures. Respondents reported low self-efficacy regarding environmental history-taking, discussing environmental exposures with parents, and finding diagnosis and treatment resources related to environmental exposures. The probability of self-reported history-taking varied with the specific exposure, with environmental tobacco smoke and pets most frequently queried and asbestos, mercury, formaldehyde, and radon rarely queried. The pediatricians' preferred information resources include the American Academy of Pediatrics, newsletters, and patient education materials. Pediatricians are highly interested in pediatric environmental health but report low self-efficacy in taking and following up on environmental histories. There is considerable opportunity for training in environmental history-taking and for increasing the frequency with which such histories are taken.

Frequency of occupational health concerns in general clinics

Studies have suggested that occupational disease and injury are under-recognized by clinicians. To estimate the frequency of occupational factors in disease and injury, 108 patients in a general (not occupational) health care facility were interviewed about the frequency and types of workplace-health interactions. Thirty-nine percent reported possible causation by work, and 66% reported a possible increase in symptoms by work, even if not caused by work. Twenty-seven percent reported changing jobs and/or tasks because of work-health interactions. The majority of men and women reported that worksite changes could improve their functional ability at work. This study therefore indicates that (1) occupational health concerns are common in primary care clinics, even if not addressed by clinicians; (2) the definition of occupational health concerns should be broadened to include disease caused by work, disease symptoms worsened by work, and the need for occupational accommodation even if the disease itself is not caused by work; and (3) inquiring about patient concerns about workplace-health interactions can provide clinicians with significant opportunities for primary, secondary, and tertiary prevention.

Adolescent occupational exposures and pediatric-adolescent take-home exposures

Thousands of adolescents are employed and routinely incur occupational exposures as part of their work. Case reports of adolescent exposure-related fatalities and illness, coupled with observational studies of chemical and other exposures with potential health risks, create a strong case for better tracking of work-related exposures and illness, better training for all working adolescents, education of their parents about risks, more clinical involvement in the health and safety of working adolescents, and advocacy for safer adolescent work environments. Because adolescents are neither children nor adults, much research is needed to clarify exposure patterns and risks; however, existing data on adolescent occupational injury and knowledge of exposures to adults in similar work environments permit immediate interventions. The most applicable information from the growing knowledge of environmental health in young children also can be borrowed and applied, especially to younger workers, such as those on farms, who may be children rather than adolescents. Crucial to future protection of working youth from occupational exposures are application of knowledge that already is possessed about occupational risks to adults, a cultural change in the way the US population views risks of chemical exposures, and improved occupational health and safety protection for all adult workers. Improving occupational health for working adolescents may be more politically acceptable and thus feasible than starting with adults, but ultimately the two are linked inextricably. These are new realms for pediatricians, but pediatrician input is needed greatly on all of these levels.

Pediatric advocacy

Advocacy is part of the job description of a pediatrician. There is a long history of pediatrician involvement in civil society. Like other skills in pediatrics, the skills required for advocacy activities are learnable. Anyone who can learn the Krebs cycle can learn how to be a child advocate. Being a child advocate is not always easy, but it is rewarding. The 1995 Nobel Prize in Chemistry was awarded to Rowland et al for their work in the description of the destruction of stratospheric ozone by chlorofluorocarbons. Having done the groundbreaking research, Rowland and Molina spent much time working to ban chlorofluorocarbons. When asked why they, as bench scientists, ventured out of the laboratory as advocates, Rowland stated, "If not me, who? If not now, when?" (personal communication, December 7, 2000).

Time and knowledge barriers to recognizing occupational disease

Traditionally, inadequate training has been considered the major barrier to recognition of occupational disease. A survey of 136 practitioners was conducted to determine which barriers were actually considered most relevant. The sample included three subgroups: primary care, occupational medicine-oriented, and Mexican. Four aggregate indices were derived: Knowledge, Time, Unpleasant aspects, and Importance. Inadequate Time was as important as inadequate Knowledge, whereas perceived lack of Importance and Unpleasant aspects were less relevant. Patterns among the subgroups were generally comparable. This study implies that training more occupational medicine specialists in increasing recognition is not sufficient unless specific strategies to overcome time constraints are also implemented. For example, emphasizing a "complete occupational history" may be counterproductive. Limiting histories to selected patients; use of focused, brief histories; and, perhaps, computer-based methods are needed.

Health information in material safety data sheets for a chemical which causes asthma

OBJECTIVE

To assess the quality of health information on material safety data sheets (MSDS) for a workplace chemical that is well known to cause or exacerbate asthma (toluene diisocyanate, TDI).

DESIGN

We reviewed a random sample of 61 MSDSs for TDI products produced by 30 manufacturers.

MEASUREMENTS AND MAIN RESULTS

Two physicians independently abstracted data from each MSDS onto a standardized audit form. One manufacturer provided no language about any respiratory effects of TDI exposure. Asthma was listed as a potential health effect by only 15 of the 30 manufacturers (50%). Listing asthma in the MSDS was associated with higher toluene diisocyanate concentrations in the product (P <.042). Allergic or sensitizing respiratory reactions were listed by 21 manufacturers (70%).

CONCLUSIONS

Many MSDSs for toluene diisocyanate do not communicate clearly that exposure can cause or exacerbate asthma. This suggests that physicians should not rely on the MSDS for information about health effects of this chemical.

Reinforcement of occupational history taking: a success story

BACKGROUND

This article describes the results of a retrospective study of 3 classes of medical students who participated in a targeted occupational and environmental health curriculum at the University of Connecticut School of Medicine.

PURPOSE

We wanted to determine if targeted focused curricular interventions which integrated occupational and environmental health principles into routine history taking would result in increased scores on the number of questions posed during the Clinical Skills Assessment Program in the 4th year.

METHODS

We analyzed Clinical Skills Assessment Program questions for 3 graduating medical school classes from 1997 to 1999.

RESULTS

It appears that intense, focused training may increase the occupational and environmental questions which students ask. By revisiting the components of the history during the 3rd year, the final assessment of 4th-year students substantially and significantly increased.

CONCLUSIONS

Those who wish to stem the decline in history-taking skills as students enter their clinical years should consider reinforcing these skills using structured programs and practice in areas of the history that are traditionally neglected but recognized as essential in gathering comprehensive data on patients.

Occupational and environmental medicine and primary care

This article introduces occupational and environmental medicine (OEM) to physicians in other specialties, and especially to primary care physicians, by highlighting the common foundations of OEM practice and primary care practice. These common foundations include careful diagnosis and treatment, appropriate use of consultants, collaboration with non-medical professionals, attention to psychosocial issues, care of the entire family, respect for confidentiality, patient education, preventing disability and maximizing function, diligent patient follow-up, epidemiological thinking, and continuing medical education.

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.

Intelligent database generated occupational questionnaire system

Obtaining an adequate occupational history requires special expertise to "ask the right questions" that are relevant to a particular patient's specific health conditions and potential exposures. This article describes a way to systematically accomplish this by means of a computer system that can overcome limited availability of necessary clinical occupational health expertise. The Intelligent Questionnaire system is a computer-based system for generating case-specific questionnaires about the influence of work on respiratory disease. Intelligent Questionnaire includes three databases: Questions, Responses, and Calls (clues to identify questions). The Questionnaire also arranges questions in a logical manner and provides a customized data entry screen for each subject. This approach provides primary practitioners with expertise on a case-by-case basis. It also facilitates occupational health surveillance because it allows acquiring detailed case-specific information in a systematic fashion. A computer-based system can facilitate obtaining occupational histories with high specificity and consistency without depending on general availability of a human occupational health clinical expertise.

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

Medical schools have been slow in teaching students how to recognize and intervene in occupationally and environmentally related illnesses. In this article, we report on the efforts at one medical school, in which an occupational medicine physician teamed with medical school educators developed, implemented, and evaluated an environmental/occupational medicine (EOM) curriculum that was introduced in several locations, using a thematic approach. This effort resulted in new EOM content being added to eight core courses in a developmental sequence and the creation of several elective experiences. We describe techniques and strategies that might be useful at other institutions in promoting the EOM theme and improving communication. Occupational/environmental physicians and educators can play leadership roles in raising interest in EOM within the medical school setting and in developing and implementing an EOM curriculum.

Occupational history collection by third-year medical students during internal medicine and surgery inpatient clerkships

Occupational history is fundamental for the evaluation of possible workplace influences on health. We reviewed 2,922 initial history-and-physical reports from 137 third-year medical students to examine occupational history collection. Overall reporting frequencies were recorded as the following: industry, 55.8%; occupation, 70.0%; specific occupational exposure, 8.4%; smoking status, 91.4%. Patients younger than 40 years of age and women were significantly less likely than other older patients and men to have notations of occupation and industry. Surgery students were less likely than internal medicine students to collect data for industry (41.6% vs 66.6%, P < 0.001), occupation (57.4% vs 79.7%, P < 0.001), and smoking (88.1% vs 94.0%, P < 0.001). The highest frequencies of notation were those for circulatory and respiratory conditions. No significant differences were noted for student gender, academic quarter, or week of clerkship. Clinical occupational medicine teaching should emphasize the need to collect occupational information from all patients, including women and young persons.

Environmental health concerns in urban and rural family practice

OBJECTIVE

To describe environmental health problems encountered in some Ontario family practices and to describe differences between the environmental concerns of urban (small and large) and rural physicians.

DESIGN

A self-completed questionnaire was mailed to 536 family physicians with hospital affiliations in three areas of Ontario.

SETTING

Family practices (rural, small urban, and large urban) in Ontario.

PARTICIPANTS

Of 521 eligible community family physicians with hospital affiliations, 214 returned usable questionnaires for a 41% response rate.

MAIN OUTCOME MEASURES

Environmental health problems encountered in practice were measured using questions about physician concerns, reported patient questions, physician-identified high-risk groups, problems related to environmental exposure, self-rated knowledge, and current and preferred sources of information on environmental health effects.

RESULTS

Physicians were highly concerned and reported many patient questions about the health effects of environmental exposures. Pregnant women, agricultural workers, and children were considered important at-risk groups. Self-ratings of knowledge were generally very low. Rural physicians were concerned about agricultural pesticide exposure and their patients about moldy hay. Urban physicians had different concerns about lead and reported patient concerns about exposure to Great Lakes fish. All groups used similar sources of current environmental health information.

CONCLUSIONS

Family physicians who participated in this study identified important patient and professional concerns about environmental health issues and reported a lack of resources to meet those concerns. This study provides information to family medicine residency programs and continuing medical education providers to help them enhance their focus on environmental health.

The occupational and environmental medicine gap in the family medicine curriculum: needs assessment in South Carolina. Part I

The occupational and environmental medicine (OEM) gap in US medical education is widely recognized. In 1992, a federal initiative stimulated a primary care approach to improve residency training in South Carolina. This three-part report documents progress in designing and implementing an OEM curriculum, which is family medicine-centered. Each of the state's residency training programs participate in an ongoing Environmental Medicine Curriculum Committee effort. Part 1, discusses the needs assessment; Part 2, the five key elements of curriculum; and Part 3 details a clinical guide to the OEM patient.

Respiratory health services reported by U.S. mining facilities in the National Occupational Health Survey of Mining (1984-1989)

This report describes the involvement of mine management personnel at U.S. mines in providing environmental and medical services related to respiratory health. The data were obtained by means of a questionnaire that was administered to mine management personnel at 491 mines and mills during May 1984 to August 1989. The data indicate that 62% of U.S. miners worked at facilities that provided at least a portion of workers with chest X-rays, and 41% worked at facilities that provided at least a portion of workers with pulmonary function tests. Eighty-five percent of miners worked at facilities in which the company required a medical examination of all new employees; the majority were required by company policy to have a medical examination before returning to work after an illness. However, only 2% of miners were required by company policy to have an exit medical examination when their employment ended. This report underscores the need for respiratory health to remain a primary concern of all persons who provide occupational health services to miners.