AAMC Reporter: July 2006

Medical Educators Focus More on Environmental Health

Medical students may not be receiving adequate instruction about the role the environment plays in the onset and progression of disease, even though environmental factors are known to exacerbate a growing number of illnesses.

Since 2000, results of the annual AAMC Graduation Questionnaire (GQ) have indicated that at least 40 percent of students feel that instruction in the closely related field of occupational medicine is inadequate. Until this year, the GQ did not specifically ask about instruction on environmental effects on health; the results of the 2006 survey will be available in September.

Research on environmental health, a relatively new area of medicine, has in the past decade or so become increasingly imperative as more is learned about the complex interplay of genes, health, and environment. "Environmental health" is generally defined as the effects on health of any unnatural component of the environment. Air pollution from automobiles; chemical contamination, such as mercury, in water; and food additives such as high-fructose corn syrup, which is linked to obesity and some types of diabetes; are all considered to be environmental threats to health.

The adverse effects on health are significant, with an estimated 25 percent of preventable illnesses worldwide attributed to poor environmental quality, according to the Healthy People 2010 national guidelines on disease prevention. In the United States, 50,000 premature deaths and $40 billion to $50 billion in annual health-related costs annually are associated with air pollution alone.

One of the reasons for the perceived instructional deficit in this area is that many present-day medical school curricula simply do not have room for additional courses, according to Marschall S. Runge, M.D., Ph.D., Marion Covington Distinguished Professor of Medicine, chair of the department of medicine, and president of the University of North Carolina (UNC) Physicians at the UNC-Chapel Hill School of Medicine.

That is not to say, however, that environmental health is not taught in medical schools. UNC's curriculum, like those of some other schools, does cover environmental effects on disease in its basic science courses in genetics and genomics, Runge explained. The later clinical years, however, do not focus on recognizing and treating specific environment-related diseases.

UNC has addressed this lack by incorporating into the third and fourth years several full-day case studies of specific diseases that have an environmental cause, such as breast cancer. Experts from a range of disciplines, including the basic sciences, clinical medicine, surgery, and epidemiology, present information to students, said Runge, adding that "it's a chance to really think very broadly about diseases."

While some educators may feel that it is difficult to fit additional coursework into already full schedules, it appears that an increasing number of medical schools are taking steps to include environmental health.

In the 2004 annual survey conducted by the Liaison Committee on Medical Education (LCME), only 71 schools, or 57 percent, reported that they required students to complete coursework in environmental health. One year later, 89 schools, or 71 percent, reported that students were required to complete studies in this area.

Rika Maeshiro, M.D., M.P.H., assistant vice president for public health and prevention in the AAMC's Division of Medical Education, said that, historically, practicing physicians have not become involved in environmental health issues, but that situation is now changing because of greater understanding of the environment-gene interactions and their effects on health.

"They may not be environmental health specialists, but having an appreciation of the environmental impact on the health of their patients is very important," Maeshiro said.

In 1996, two physicians at Harvard Medical School, Eric Chivian, M.D., assistant clinical professor of psychiatry, and Paul R. Epstein, M.D., M.P.H., instructor in medicine, recognized the magnitude of environmental health effects and founded the Center for Health and the Global Environment. For the past nine years, the center has offered a semester-long elective course called "Human Health and Global Environmental Change."

Open to all Harvard students, students at the Massachusetts Institute of Technology, students at Tufts University's Fletcher School of Law and Diplomacy, and members of the public. Other medical schools can access the course at http://chge.med.harvard.edu/education. So far, 65 schools have used the course, according to Kathleen Frith, the Center's communications director.

Four years ago, several Harvard students were so struck by what they learned in the course that they formed a student-interest coalition called Students for Environmental Awareness in Medicine (SEAM). This student-led group is now a nonprofit organization affiliated with other groups of medical students nationwide. In February 2005, SEAM and the Physicians for Social Responsibility cosponsored a conference in Washington, D.C., for 30 medical students from across the country. While in Washington, some of these students presented congressional staff with a petition outlining their concerns about environmental effects on health.

Christine Pace is one of the students who participated in the D.C. conference and a fourth-year medical student at Harvard. Pace feels that physicians have the responsibility to become politically involved in environmental issues.

"As physicians, if we are at all concerned with issues of prevention," Pace wrote in a recent e-mail, "we must be educated about environmental change and also about environmental issues relevant within our communities and how to refer our patients to agencies that can help them with specific local problems such as indoor air pollution."

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