Reproductive Environmental Health Education for Health Professionals

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Summary

Increasingly, research is demonstrating links between exposures to contaminants in the environment and human disease. Unfortunately, physicians in training may not be learning what they need to know to care for people affected by environmental health issues. There has been growing concern about the current state of environmental and public health education in US medical schools, both in terms of what is taught and the lack of emphasis placed on these issues in the curriculum. (IOM 1995 http://www.nap.edu/catalog.php?record_id=4795, Etzel RA et al, 2003. doi:10.1367/1539-4409(2003)003<0060:PEHCFS>2.0.CO;2). Current training of medical professionals also includes little education on reproductive environmental health, which is currently not covered in the medical school, ob/gyn residency, and fellowship training settings.

Obstetrician/gynecologists are physicians who have completed a 4 year residency to specialize in the care of women's reproductive health throughout their lifespan and during pregnancy. Many OB/GYNs also provide primary care for women. They provide well-woman care, prenatal care, deliver babies, and to perform surgeries such as hysterectomy. As such, they interact with women throughout the lifespan, and are uniquely positioned to provide patient education on topics related to environmental health.

Maternal Fetal Medicine (MFM) specialists are OB/GYNs who have completed an additional 3 year fellowship (formal education and clinical experience) to gain special competence in the diagnosis and treatment of women with complications of pregnancy. MFM specialists care for women whose pregnancies are complicated by problems with the fetus (eg birth defects) as well as pregnancies that are complicated by medical conditions affecting the woman (eg diabetes). They are experts in ultrasound and the diagnosis of birth defects. In addition, MFM specialists provide much of the education of medical students, residents, and practicing physicians regarding complications of pregnancy and birth defects, as well as much of the research concerning obstetrical problems.

During OB/GYN residency training, OBGYN residents (who already have their MD degree) learn to care for women across the reproductive spectrum from puberty to menopause, both in the hospital and in the clinic setting. They learn how to provide well-woman care, prenatal care, deliver babies, and to perform surgeries such as hysterectomy. Because they interact with women throughout the lifespan, educating OB/GYN residents in environmental health will allow the dissemination of environmental health education to women during crucial moments, including during the preconception period and pregnancy.

During MFM fellowship, MFM fellows (who have already completed an OB/GYN residency) spend 3 years gaining special knowledge of pregnancy complications. This time is spent in the hospital, in the clinic, and doing research. Fellows learn to care for women with complicated pregnancies and they become experts in ultrasound and the diagnosis of birth defects. Again, because they are interacting with women during "teachable moments" during pregnancy, they are ideally positioned to provide environmental health education. Furthermore, because they are often the first to make the diagnosis of a fetal anomaly, they are positioned to engage in research efforts to clarify the risks of environmental exposures. Education of MFM fellows provides a unique opportunity to amplify awareness in the medical community and general population through the teaching of patients, family members, as well as future generations of medical students and OB/GYN residents.

The proposed UCSF environmental health curriculum for the health professions plan would insert reproductive environmental health education at all levels of physician training. In the core curriculum of medical school, EH would be taught in the mandatory 2nd year medical student class "Life Cycle," with the effect of repro env exposures in fertility, pregnancy, and childhood. Additionally, further coursework would be available on an elective basis in the 2nd through 4th years of medical school. REH would be taught in OBGYN residency and MFM fellowship training at UCSF, initially as elective rotations, but with the ultimate intent of integration into the mandatory curriculum. REH would also be inserted into the curriculum as part of continuing medical education lectures, "Grand Rounds," and outreach education for physicians in practice.

The proposed residency and fellowship rotations would require the development of curriculum that would include didactic training in the science of REH (precautionary principle, timing of exposures, developmental susceptibilities, mechanisms of metabolism, exposure half-lives, transplacental passage, etc) as well as the clinical manifestations of common and uncommon reproductive toxicants, including lead, mercury, and endocrine disrupters. In addition to didactic training, residents and fellows will attend clinics through the Region 9 PEHSU to gain hands-on experience in the diagnosis, management, and education of patients with environmental health exposures. Development of the curriculum will include attention to the previously established competencies and objectives in environmental health put forward by the Ambulatory Pediatric Association, the American College of Occupational and Environmental Health, and the Institute of Medicine. The curriculum for the medical trainees will adhere to the guidelines of environmental education put forth by the EPA, using Guidelines for the Preparation and Professional Development of Environmental Educators. www.epa.gov/education/resources.html. The REH curriculum will also require completion of a project intended to disseminate REH education. For example, a trainee might review the CDC's recommendations for diagnosis and treatment of lead toxicity in pregnancy and create a training program and posters for prenatal care providers in the local county clinics. Another example would be using local data to identify areas of the community with the highest risks of lead toxicity and to target community outreach to teens and pregnant women in those areas. The project requirement will enable more rapid dissemination of knowledge to providers and the community.

The education of OB/GYNs and MFM specialists in training will allow the rapid dissemination of REH education directly to women planning pregnancies, currently pregnant, and with young children. Additionally, educating these physicians will allow for dissemination of REH knowledge throughout the medical field.