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Faculty Training Guide
In recognition of this fact, the Residency Review Committee of the American Council of Graduate Medical Education requires, as of 1996, that all pediatric physician residency programs include environmental health in their curriculum. Curriculum guide-lines from the National Organization of Nurse Practitioner Faculties (1996) provide a framework for environmental health but do not address the topic directly. This module is designed to help teaching faculty and those involved in curriculum development to integrate pediatric environmental health training components into their educational programs. This module, with the accompanying module "Strategies and Tactics for Teaching" offers strategies and evaluation tools to assist faculty. The accompanying set of training modules provides suggested course content. An Introduction to Pediatric Environmental Health What is Pediatric Environmental Health? Pediatric environmental health is:
The field of pediatric environmental health is multidisciplinary and encompasses medicine, nursing, environmental health sciences, public health, epidemiology, and public policy. An Overview of Pediatric Environmental Health Children today live in an environment that is vastly different from that of previous generations. Currently 70,000 manufactured chemicals are in common use, and their impact on health is in most cases unknown (Schaefer, 1994). While exposures to some environmental hazards have been decreased through new regulations and standards, children continue to be exposed to many unregulated toxicants in air, water, and food. Children can encounter environmental toxicants in the home, school or day care settings, recreational locations, workplaces, and in the larger community environment, whether urban or rural. Many adverse health effects from environmental exposures are well documented. Research has linked the exacerbation of asthma and other respiratory problems to high levels of air pollution (Etzel, 1995). Although lead levels in children have dropped significantly since 1976 due to intensive federal, state, and local actions, a significant percentage of our children remain at risk for neurological impairment from lead poisoning (Pirkle, et al, 1994). Pesticides are another cause of concern: associated health effects include neurological impairments and cancer. Children have been poisoned from aldicarb in watermelon (Rosenstock, 1991), and may regularly encounter pesticides residues in food and drinking water. Many youngsters are also exposed to pesticides occupationally. Health effects that have been associated with pesticides include neurological impairments and cancer. The list of medical conditions that may have an environmental link continues to grow. For example, scientists are beginning to question whether low-level neurotoxic exposures are related to an apparent increase in attention deficit disorder in children. Wildlife data suggest that exposures to certain pesticides may disrupt the development of the endocrine and reproductive systems (Colborn, 1990; EHP, 1993). Children are particularly vulnerable to environmental exposures for the following reasons: they are developing organisms; they have heightened biological sensitivity; they engage in exploratory behavior that increases their risk of exposure to toxicants; and because their diet may increase their exposure to toxicants. Developing Organisms Children's immature organ systems are especially sensitive to environmental hazards. In particular, exposure to environmental toxicants may disrupt and cause permanent damage to the developing nervous, immune, and respiratory systems of young children (Bearer in EHP, 1995, Needleman, 1990). Biological Sensitivity The metabolic and physiological processes of children differ dramatically from those of adults. Children's skin, respiratory, and gastrointestinal absorption of toxic materials is greater than that of adults. They cannot metabolize, detoxify, and excrete certain toxins as well as adults, and are thus more vulnerable to adverse health effects (Ecobichon, 1973; Snodgrass, 1992). Behavior Normal exploratory behaviors, such as hand-to-mouth activity and crawling on the ground or floor, increase children's opportunities to encounter and ingest toxicants such as lead-based paint dust (Bearer, 1995). The relatively large amount of time children spend outdoors, often at high activity levels that raise their rate of respiration, make children more susceptible than adults to the ill effects of air pollution (Bearer, 1995). Diet The National Academy of Sciences Report, Pesticides in the Diets of Infants and Children, states that infants and children differ both qualitatively and quantitatively from adults in their exposure to pesticide residues in food (National Research Council, 1993). Per unit body weight, children consume more of such foods as apples and bananas and drink more water than adults. Both dietary factors may result in heavier exposures to toxicants (Schaefer, 1994). Of particular concern in infants and children are: exposures to pesticide residues on apples and other favorite fruits and vegetables; lead in water and dust; and polychlorinated biphenyls (PCBs) and dioxins in breast milk. The Role of the Health Care Provider in Environmental Health A combination of knowledge and skills is needed for competency in pediatric environmental health. Health care providers should have a basic understanding of epidemiology, toxicology, and the effect of environmental hazards on various stages of human development. Health care providers must also learn the specifics of diagnosing, treating, and preventing exposures to common toxicants, including: environmental history taking/home assessment; risk-communication; reporting requirements; and advocating for environmental change within the community. The health care provider should serve as an: Investigator Health care providers are the frontline investigators of environmental-related illness within the clinical setting and the community. A careful health history and familiarity with environment-related symptoms are the keys to diagnosing environmental illness in children. Health care providers can work with appropriate agencies to identify trends and contribute to clinical research on environmental exposures of concern to the community. Educator Knowledgeable providers are a credible source of information to patients, their families, and communities. Information shared by the provider can inform individuals and communities in their efforts to reduce or eliminate toxic exposures and create an environmentally "safe" home, school, and day care setting. Advocate Providers who treat the adverse effects of environmental exposures in society's youngest members can be compelling advocates for more preventive and protective policies at the local, state, and national levels. Rationale for Integrating Pediatric Environmental Health into Educational Programs for Health Care Professionals Why should a teaching institution or a faculty member care about pediatric environmental health? The following rationale outlines a series of key reasons: New Program Requirements for Residency Programs Pediatric environmental health is a growing discipline within primary care. It has been incorporated into program requirements by the Residency Review Committee for Pediatrics. Pediatric residency curricula must, as a result, include instruction in interviewing techniques that will allow residents to identify environmental correlates of disease, and community experiences wherein residents can learn about and observe the effects of environmental toxicants on child health. Demonstrated Effectiveness A pilot project to integrate environmental health components into the pediatric residency was conducted at Children's Hospital of Oakland, in Oakland, California, between 1990-92. The introduction of material on environmental illness was shown to "markedly affect pediatric residents' behavior in assessing environmental causes for common illnesses." (Bearer, 1993) A retrospective chart review showed a significant difference in the number of environmental questions asked by the group of trained residents compared to residents who did not receive the training. Existing Educational Frameworks Can Accommodate Pediatric Environmental Health Major alterations to the educational program are not required in order to incorporate pediatric environmental health into primary care. Components can be easily integrated in a longitudinal fashion. Environmental Protection is a Growing Societal Concern Public opinion polls indicate that the environment is crucially important to the American people, and that they are specifically concerned about exposures to their children (Coalition for America's Children, 1995; Pew Charitable Trusts, 1999). An analysis of a base-line survey by the Environmental Protection Agency in 1990 entitled Public Knowledge and Perceptions of Chemical Risks in Six Communities found that health professionals had the highest trust level in these communities, but were not perceived as being very knowledgeable about environmental hazards in the community (McCallum, 1990). When study respondents were asked where they would like to obtain information about environmental hazards, many mentioned physicians' offices, along with schools, PTAs, drugstores, and libraries (ibid.). Pediatric training needs to prepare practitioners to provide this information. Environmental Health is a Key Component of Primary Care Environmental health is relevant to all areas of health care and is a crucial part of primary care. The preventive nature of environmental health offers opportunities for health care professionals to deal with root causes of disease, morbidity, and mortality. The Institute of Medicine (IOM), in two 1995 reports entitled: Environmental Medicine: Integrating a Missing Element into Medical Education; and Nursing, Health and the Environment, describes the integral relationship between the environment and health, a relationship that requires the active participation of knowledgeable physicians and nurses in both clinical and community settings (Pope and Rall, 1995; Pope, Snyder and Mood, 1995). In a previous seminal report published in 1988, the IOM called for enhanced physician education and training in the area of occupational and environmental medicine. The same report confirmed that primary care physicians are often the first health professionals contacted by patients with environmentally-related illnesses and suggested that "at a minimum, all primary care physicians should be able to identify possible occupationally- or environmentally-induced conditions and make the appropriate referrals for follow-up" (Institute of Medicine, 1988). Benefits to the Teaching Institution Teaching institutions can reap a variety of benefits by adding environmental health components to their pediatric programs.
Strategies for Incorporating Pediatric Environmental Health into Health Professions Training Programs Faculty members may elect to employ any or all of the following strategies to integrate pediatric environmental health into their educational program.
Review New Program Requirements for Residency Education in Pediatrics New requirements for incorporating pediatric environmental health in residency training programs became effective in February 1997. They are:
These same requirements can be adapted for all health care professionals: Assess Your Institution Educational programs vary considerably in their structure, and may require customized strategies for integrating pediatric environmental health into the curriculum. Conducting an inventory of existing environmentally-related training and resources is a recommended first step in this process. Identify and assess faculty interest and expertise in pediatric environmental health. Identify colleagues and allies in other disciplines who can serve as resources. Use the worksheet below to sketch the structure of your program and identify which training components are most suited for the addition of pediatric environmental health curricula. Further detailed guidance on conducting an inventory can be found in Environmental Medicine: Integrating a Missing Element Into Medical Education, published by the Institute of Medicine (Pope and Rall, 1995).
Develop an Awareness of Local Community Concerns Learn about environmental hazards that affect the local community. Tailor your program to provide health care providers with the knowledge and skills to diagnose, treat, and prevent these hazardous exposures. Encourage program directors of community-based training sites to address environmental health and develop materials for their use. Educate Faculty and Administrators Give a brief presentation to colleagues and administrators about the field of pediatric environmental health and its relevance to primary care and the institution. Use the Introduction module to highlight the main concepts of pediatric environmental health. The presentation should:
Collaborate with Faculty and Administrative Colleagues in Developing a Plan to Integrate Pediatric Environmental Health into Your Program Work closely with curriculum committees and institutional task forces concerned with health promotion, disease prevention, and public health. Determine who needs to be involved, what resources are required, and develop a plan for implementation.
Identify Potential Funding Sources Cite potential funding resources to support faculty and programs that incorporate environmental health into primary care, such as NIEHS grants for faculty development and research, and pharmaceutical foundation grants. Resources for Teaching Pediatric Environmental Health Training Manual The modules in this manual address different knowledge and skill areas in pediatric environmental health. Each module includes key content areas, teaching methods, visual aids (as applicable), questions for discussion, and evaluation methods. Case Studies Case studies can be used by faculty in a number of training activities, such as Grand Rounds or noon conferences, and discussions with students and residents. Case studies are included in some of the modules, but may need to be tailored to your specific geographical region. The Agency for Toxic Substances and Disease Registry has developed a series entitled Case Studies in Environmental Medicine, a number of which focus on children. The case studies can be ordered directly from ATSDR or can be found in Environmental Medicine: Integrating a Missing Element into Environmental Medicine. Lecture Series The modules in this manual may be used to develop a Grand Rounds lecture or series of lectures on pediatric environmental health. You can identify experts who may be available to give lectures at your institution through the Education Project of the Children's Environmental Health Network. Community Resources for On-Site Training Local public health officials and community leaders can help you identify resources to use in teaching residents. You can also contact the Association of Occupational and Environmental Clinics to locate the AOEC member clinic in your area. You may also identify field sites where students and residents can learn more about environmental hazards in the community. Evaluating the Pediatric Environmental Health Program This training guide provides strategies for incorporating pediatric environmental health into your educational program. As you implement these strategies, it is important to monitor your progress. Evaluating the training program enables you to improve its effectiveness. Evaluation will allow faculty to:
This section provides a discussion of both quantitative and qualitative evaluation methods, in addition to a variety of assessment tools for use in evaluating the success of your efforts. Discussion focuses on the evaluation of learners, as well as your evaluation of your efforts to incorporate pediatric environmental health into your educational program, pediatric department, or institution. In ideal circumstances, evaluation would include four assessment periods: pre-training, immediate post-training, one-year post-training and three-years post-training. The pre-training assessment serves as a bench mark for prior knowledge about pediatric environmental health. Immediate post-training assessment typically reflects changes in awareness. Evaluation at one and three years post-training provides a measurement of sustained effects and is more reflective of changes in behavior. Evaluating the Learner Evaluation measures the extent to which learners have grasped principles of pediatric environmental health and are able to demonstrate competencies in specific areas. Most health care institutions have existing evaluation systems that can be easily adapted to include environmental health. Strategies for evaluating learners which may already be in place include the following:
A common approach to evaluation is to assess changes in knowledge, attitudes, and behavior. Knowledge Knowledge measures gained factual information about pediatric environmental health. Knowledge is most commonly evaluated through written or oral examinations. A written or oral exam could, for example, ask the learner to list and explain the core principles of pediatric environmental health. Some examples of other knowledge-based questions are provided below:
Knowledge also encompasses an awareness of institutional and community resources. A learner could be given a case study of a child admitted to the hospital with symptoms of lead poisoning and be asked to respond to the following questions:
Attitudes Attitudes refer to the manner in which a learner thinks about a child's health and incorporates the principles of environment health into patient care. Attitudes are best assessed through direct observation of the learner's clinical interaction with patients. They can also be evaluated with the use of attitude scales. Behavior Behavior describes the way in which learners conduct themselves or how they interact with the patient. Direct observation at a weekly clinic and chart audits are effective ways to assess behavior changes. An example of the chart audit as an effective evaluation instrument is presented by Cynthia F. Bearer, MD, PhD and Rachel Phillips in the article entitled "Pediatric Environmental Health Training: Impact on Pediatric Residents", published in American Journal of Diseases of Children, June 1993 (Bearer, 1993). A copy of the article is included in the Appendix of this module. In 1991, the California Department of Health Services, in conjunction with Children's Hospital Oakland and the Children's Environmental Health Network (then called the Kids and the Environment Project), conducted a training course for pediatric residents on the topic of children and toxic hazards. After the eight session course was completed, the charts of children admitted to the hospital with a diagnosis of asthma were compared to those of a control group admitted prior to the course in order to assess the impact on residency training. The study revealed a significant increase in the number of environmental questions asked by pediatric residents who received the training (Bearer 1993). Evaluating the Educational Program It is equally important to assess the extent to which environmental health has been incorporated into your educational program. This assessment can easily be conducted as part of the program's regular evaluation process. Three areas of consideration are: teaching curriculum, faculty development, and community involvement. Examples of relevant questions for each area are provided below. Teaching Curriculum
Faculty Development
Community
The commitment of deans and department heads to a particular discipline or philosophy has significant impact on the behavior and studies of that body's faculty members (AAMC, 1983). Thus, an especially insightful method of evaluation may be to interview program directors and determine his or her level of interest in environmental health and awareness of faculty involvement in this field. Summary of Barriers and Applicable Strategies
References Association of American Medical Colleges (AAMC). General and Professional Education of the Physician and College Preparation for Medicine. Washington, DC: AAMC, 1983. Bearer CF. How are children different from adults: preventing child exposures to environmental hazards: research and policy issues. Environmental Health Perspectives 103 (6):7-12 (1995). Bearer CF, Phillips R. Pediatric environmental health trainingóimpact on pediatric residents. American Journal of Diseases in Children 147:682-684 (1993). Coalition for American Children: Key Findings from the Coalition for American Children Survey, September 1995. Colborn T, Clements C, eds. Chemically-Induced Alteration in Sexual and Functional Development: The Wildlife/Human Connection. Princeton, NJ: Princeton Scientific Publishing, 1992. Echobichon DJ, Stevens DS. Perinatal development of human blood esterases. Clinical Pharmacology Therapy 14:14-47 (1973). Etzel R. Indoor air pollution and childhood asthma: effective environmental interventions. Envir Hlth Persp 103 (6):55-58 (1995). Institute of Medicine. Role of the Primary Care Physician in Occupational and Environmental Medicine. Washington, DC: National Academy Press. 1988. McCallum DB, Hammond SL, Morris LA, Covello VT: Public Knowledge and Perceptions of Chemical Risks in Six CommunitiesóAnalysis of a Baseline Survey. In Risk Communication Series #EPA 230-01-90-074. Washington, DC: Environmental Protection Agency. January 1990. National Research Council. Pesticides in the Diets of Infants and Children. Washington, DC: National Academy Press, 1993. Needleman HL, Gastonis CA. Low-level lead exposure and the IQ of children: a meta-analysis of modern studies. J of Amer Med Assoc 263:673-678 (1990). Needleman HL, Schell A, Bellinger D, et al. The long-term effects of exposure to low doses of lead in childhood: 11 Year Follow-up Report. N Engl J of Med 322:83-88 (1990). The Pew Charitable Trusts. Analysis and presentation of findings: attitudes toward public health. Mellman Group, Inc. and Public Opinion Strategies Inc. (1999). Pirkle JL, Brody DJ, Gunter EW, Kramer RA, Paschal DC, Flegal KM, Matte TD. The decline in blood lead levels in the United StatesóThe National Health and Nutrition Examination Surveys (NHANES). JAMA. 272(4):284-291 (1994). Pope AM, Rall DP, eds. Environmental Medicine: Integrating a Missing Element into Medical Education. Washington, DC: Institute of Medicine (National Academy Press). 1995. Rosenstock L, Rest K, Benson JA, et al. Occupational and environmental medicine. N Eng J of Med 325:924-927 (1991). Schaefer M. Children and toxic substances: confronting a major public health challenge. Env Hlth Persp 102 (2):155-56 (1994). Snodgrass WR: Physiological and biochemical differences between children and adults as determinants of toxic response to environmental pollutants. In Guzeliam PS, Henry CJ, Olin SS, eds.: Similarities and Differences Between Children and Adults. Washington, DC: International Life Sciences Institute Press, 1992:35-42. US Department of Health and Human Services: Mercury exposure from interior latex paintóMichigan. MMWR 39:125-26 (1990). |
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