TRIGGERED INQUIRY: EDUCATING MEDICAL STUDENTS HOW TO RECOGNIZE AND RESPOND TO ENVIRONMENTAL EXPOSURE

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TRIGGERED INQUIRY EDUCATING MEDICAL STUDENTS
HOW TO RECOGNIZE AND RESPOND TO ENVIRONMENTAL
EXPOSURESS. Reddy1 T. Graber2 D. Osterholt1
C. Bearer 1,3 1Case Western Reserve University,
Cleveland, OH 2St. Vincent Charity Hospital,
Cleveland, OH 3Rainbow Babies Children
Hospital, Cleveland, OH
Scholars Collaborationin Teaching and
Learning2005-2006
Statement of Problem
What would YOU ask a patient?
In order to assess their exposure to
environmental hazards, what would you ask a
patient who presents with the following
triggers? Triggers are characteristics of a
patient or findings presented during a patient
encounter that should prompt us to think about
potential environmental problems (lift up
picture to see appropriate questions to ask each
of these patients)

• Environmental hazards significantly impact the
  health of individuals and communities
• Poor environmental quality is directly
  responsible for about 25 of
• all preventable ill health in the world1
• Environmentally-attributable disease in American
  children are
• estimated to cost 54.9 billion annually2
• Physicians are inadequately trained to
  appropriately respond to problems relating to
  environmental exposures. This deficiency is
  detrimental to the health of both patients and
  communities.
• Twenty-four percent of medical schools do not
  require
• environmental medicine content in the
  curriculum3
• Of the medical schools that include
  environmental medicine,
• an average of seven hours of instruction are
  devoted to this subject3
• Less than half of pediatric programs include
  pediatric
• environmental health issues other than lead
  poisoning and asthma4
• A survey of clinicians found that approximately
  half had not had
• any training related to environmental health5
• Consequently, a growing number of institutions
  are calling for an increase in environmental
  medicine training for health care providers.
• The Institute of Medicine recommends that all
  graduating medical
• students should be competent in the following
  categories

• A pregnant woman
• Ask about her diet and water intake
• Ask about environmental tobacco smoke exposure
• Ask about pesticide use or exposures to pesticide
  materials
• Ask about any new housework
• Such as painting a new nursery (solvents and lead
  dust)

• A mother and her two-month old baby
• Ask about environmental tobacco smoke exposure
• Ask if the baby is bottle-fed or breastfed
• If breastfed
• Ask about mothers fish consumption (mercury
  exposure)
• Ask about lead exposure (age of housing unit,
  renovations, etc)
• If bottle-fed
• Ask about which type of formula is used
  (manganese contamination)
• Ask about the use of tap water and whether the
  water is boiled (lead exposure and concentration
  of non-volatile chemicals)

• Young artist with numbness in hands
• Ask about which art materials are used
• Ask about what protection she uses when working
• Ask about ventilation in her place of work
• Ask about hand-mouth behavior while working

• 17 year old male for school check up
• Ask about environmental tobacco smoke exposure
• Ask about occupation and occupational exposures
• Ask about hobbies (art materials)
• Ask about whether he mows the lawn (pesticide
  use, lawn care products)

Findings to Date
Description of Program/Intervention

• This pilot educational intervention will target
  all first year medical students at Case Western
  Reserve University School of Medicine. The
  intervention will include distributing written
  and electronic resource material and designing
  and implementing an educational session. The
  pilot session will occur during the Science of
  Clinical Practice portion of the curriculum.
• 1) Written and electronic resource material will
  be distributed to all first year medical
  students, The material will include the
  following
• Description of environmental triggers. Categories
  of triggers will be presented along with specific
  toxins that are related to the triggers. For
  instance, an old housing unit is a trigger for
  potential lead exposure.
• Guidelines for taking an environmental history,
  including eliciting information about
  environmental exposures at home and work.
• Information on specific exposures. Cases
  formulated by the Agency for Toxic Substances and
  Disease Registry highlight the health effects of
  specific toxins such as arsenic, nitrates, and
  polychlorinated biphenyls (PCB).
• 2) The educational session will focus on the
  environmental health history and environmental
  exposure triggers. The session will include
• A demonstration of an environmental history
  during a well-child visit illustrating
  environmental triggers for all of the students.
• Small group discussion of case. Groups of 7 to 9
  students facilitated by two faculty members will
  discuss the case highlighting the triggers
  presented during the interview.
• Large group summary and reflection. The class
  will reconvene to summarize the history taking
  process and concept of recognizing triggers.
• The educational intervention will be evaluated by
  pre and post test cases which will be filled out
  by the students.

The written materials are being created and
assembled. We anticipate student educational
findings after the completion of this pilot
project in March. We believe that educating
students about how to take an appropriate
environmental history and how to recognize
environmental triggers is the first step towards
graduating students who are competent in
environmental medicine. This pilot intervention
is the first part of an educational intervention
designed to prepare medical students to suspect,
assess, manage and prevent environmental health
problems. UNANSWERED QUESTIONS While
recognizing our limited time with students, how
can the evaluation tool be incorporated into the
learning process.
References
Objectives of Intervention

• World Health Organization, Health and Environment
  in Sustainable development, Geneva, World Health
  Organization 1997.
• Landrigan PJ, Schechter CB, Lipton JM, Fahs MC,
  Schwartz J. Environmental Pollutants and Disease
  in American Children Estimates of Morbidity,
  Mortality, and Costs for Lead Poisoning, Asthma,
  Cancer, and Developmental Disabilities.
  Environmental Health Perspectives. 2002
  110(7)721-728.
• Schenk M, Popp SM, Neale AV, Demers RY.
  Environmental Medicine Content in Medical School
  Curricula. Academic Medicine. 1996
  May71(5)499-501.
• Roberts JR and Gitterman BA. Pediatric
  Environmental Health Education A Survey of US
  Pediatric Residency Programs. Ambulatory
  Pediatrics. Jan-Feb 20033(1)57-59.
• Liebman A, Harper S. Environmental Health
  Perceptions Among Clinicians and Administrators
  Caring for Migrants. MCN Streamline the migrant
  health news source. Volume 7, Issue 2. May/June
  2001.
• Pope AM, Rall DP, eds. Environmental Medicine
  Integrating a Missing Element into Medical
  Education, Institute of Medicine Report.
  Washington, DC National Academy Press 1995.
• National Environmental Education and Training
  Foundation. Position Statement Health
  Professionals and Environmental Health Education.
  http//www.neetf.org/Health/PositionStatement2.pdf
  . Accessed February 24, 2006.

• We propose to design an educational intervention
  for first year medical students intended to
  create an awareness of environmental hazards and
  an ability to respond to pertinent findings. Our
  objectives for this program are
• To educate students about how to take an
  appropriate environmental history and to
  recognize triggers within a patient encounter
  that should elicit further inquiry about
  environmental hazards
• To provide resources for students to learn about
  specific environmental hazards