Training Physicians in Environmental Health: A Strategy to Improve Patient Care and Reduce Healthcare Costs
The lack of environmental health education in medicine contributes to lost opportunities for physicians to prevent or intervene early in environmentally-related diseases. Despite the importance of environmental exposures on disease morbidity (the WHO estimates that 13% of total disease burden in the United States is related to the environmental risk factors), medical students receive very little training on how to recognize and manage environmentally-related diseases. On average, medical students receive seven hours of environmental health training in 4 years of medical school; approximately one-third of graduating medical students believe that their EH training was "inadequate.", 
Integrating environmental health into medical school
Although the typical medical school curriculum is very full, there are ample opportunities for seamless integration of environmental health into both pre-clinical courses and clinical rotations. Many medical schools have adapted an "organ system-based" approach to pre-clinical courses, and environmental etiologies and mechanisms of action can be incorporated into this structure. For example, the neurotoxic effects of pesticides and heavy metals can be incorporated into a neurology course. Environmental medicine can also be incorporated in medical schools that still use the traditional "basic sciences" approach to pre-clinical courses. For example, the neurotoxic effects of pesticides can be incorporated into neuro-anatomy and toxicology or biochemistry courses.
In the clinical rotations, the skills of taking an environmental and occupational history during a patient interview can be emphasized, environmental disease management strategies can be highlighted (i.e. reducing environmental asthma triggers in a patient's home), and patient referrals to relevant resources to address environmental exposures can be integrated into disease management skills. For example, patients can be referred to a lead poisoning program at the Department of Health, or to legal aid services to assist with housing quality issues.
Many medical schools have also incorporated "doctoring" courses into the pre-clinical years; these provide a great venue for teaching the importance of addressing environmental and social determinants of health. The Liaison Committee on Medical Education (LCME), which provides accreditation for medical schools, has recently modified curriculum requirements to include "public health sciences," and environmental health is a subset of this topic. Educational and clinical competencies on environmental health have been developed. Hopefully this requirement will push medical schools to better integrate environmental medicine into a student's experience over four years of training.
Opportunities for physicians to learn
After medical school is complete, there are still abundant opportunities to incorporate environmental health into a physician's training including lectures during residency programs, rotations with environmental specialists during residency, and continuing medical education (CME) lectures on environmental health for practicing physicians.
Given the large variety of possible environmental exposures in our industrial society, from air pollution to endocrine-disrupting chemicals, and given the increased media attention and general public awareness on these issues, physicians today are likely to frequently encounter environmentally-related diseases and also receive questions from patients about environmental health concerns. It would be unrealistic to expect every graduating medical student and practicing physician to be an expert in environmental medicine. However, introducing the topic of environmental health in a more substantial way during pre-clinical and clinical years (and beyond) will better equip future physicians to counsel on preventing exposures, promptly identify exposures, and make the appropriate referrals for further management when required. One such referral would be to Pediatric Environmental Health Specialty Units-PEHSUs- or to Occupational and Environmental Medicine Clinics.
To illustrate the importance of integrating environmental health into medical training and practice, consider the example of a 5-year-old child, Annie, with persistent asthma, who has had multiple emergency room visits and hospitalizations for asthma attacks in the past two years. These visits to the hospital are expensive, cause Annie to miss school, and affect her quality of life and that of her family. By taking a thorough environmental health history at clinic visit, Annie's new pediatrician, who received integrated environmental health training in medical school, quickly identified both cockroaches and bathroom mold as her two major triggers. In addition to providing refills for her controller and rescue medications, Annie's doctor referred the family to local Department of Health for mold remediation resources, provided information on integrated pest management techniques to safely eliminate cockroaches, and also referred her to the local PEHSU for further guidance about making her home environment healthier. This more comprehensive approach to asthma management, which includes environmental medicine, will likely reduce the number of emergency visits and hospitalizations for asthma, since Annie's triggers have been eliminated from her home. It will improve Annie's quality of life, lead to a healthier home environment for her and her family, and also decrease healthcare spending on hospital visits and admissions. This approach makes sense.
Importance of pediatricians, family physicians
As an environmental pediatrician, I would be remiss not to emphasize the incredible importance of increasing environmental health awareness among pediatricians and family physicians. Children are more susceptible to the effects of toxic environmental exposures. Preventing exposures at an early age can lead to a lifetime of health benefits. It can also lead to substantial healthcare cost savings; a recent study estimated that the annual cost of environmentally attributable pediatric disease in the United States (such as asthma, lead poisoning, some cancers, etc) is an astounding $76 billion. Imagine if these environmentally attributable diseases were prevented through a more coordinated and substantial effort about medical professionals, allied health professionals, and public health departments! A first step to achieving this big goal is improving training in environmental health in medical school and continuing medical education.
For physicians or allied healthcare providers that would like to learn more about the Pediatric Environmental Health Specialty Units (PEHSU), please click here.
The PEHSU system provides quality environmental medicine consultations for health professionals, parents, caregivers, and patients. The PEHSU are also dedicated to increasing environmental medicine knowledge among healthcare professionals around children's environmental health by providing consultation and training. Finally, the PEHSU provide information and resources to school and community groups to help increase the public's understanding of children's environmental health.
 Shenk M, Popp SM, Neale AV, Demers RY. Environmental medicine content in medical school curricula. Acad Med 1996; 71(5): 499-501.
 Gehle KS, Crawford JL, Hatcher MT. Integrating environmental health into medical education. Am J Prev Med 2011; 41 (4S3): S296-S301.
 Etzel R, Balk S, eds. Pediatric Environmental Health: 3rd Edition. American Academy of Pediatrics. 2012.
 Trasande L, Liu Y. Reducing the Staggering Costs Of Environmental Disease In Children, Estimated At $76.6 Billion In 2008. Health Aff 2011; 30 (5): 863-870.
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