Because they often serve on the front lines of health care, family physicians play a crucial role in identifying potential environmental hazards, educating the public about sources of environmental exposures and treating patients who have environment-related illnesses.
All that knowledge requires considerable training, however. The results of a survey(www.cfp.ca) in the June issue of Canadian Family Physician suggest that substantial gaps exist between what family medicine residents know, what they consider valuable, and how they are being trained to effectively assess and manage patient concerns related to environmental health.
The study was conducted in two parts. First, a team composed of team of Canadian family medicine program directors and several environmental health experts developed a comprehensive 93-question survey(fammedmcmaster.ca) that measured knowledge of, attitudes toward and clinical practices related to environmental health.
- A survey of more than 200 family medicine residents in Canada found gaps in knowledge and training related to environmental health.
- More than 90% of residents thought taking an environmental exposure history was important, but less than 20% received such training.
- The researchers recommended that environmental health be considered a high priority in postgraduate family medicine education.
Once the survey received ethics approval from all participating institutions, an invitation was sent to every first-, second- and third-year family medicine resident at four training programs in Ontario between November 2015 and January 2016. Each resident received three reminders over a six-week period. Ultimately, 203 residents responded.
Several questions asked residents about taking an environmental exposure history. While 92% of those surveyed thought that taking an exposure history was important, just over 18% reported having specific training in how to take one. Another 48% of residents agreed that "taking an exposure history takes up too much time in office practice."
The survey then asked residents how often they would take an exposure history in two hypothetical patients: one with poorly controlled asthma or frequent asthma episodes and one with recurrent miscarriage. More than 75% of residents said they would take an exposure history for the asthma patient half of the time or more often, but only 20% said they would do the same for the patient with recurrent miscarriage.
Residents also were asked how often they talked with patients about environmental exposures in a variety of settings using a mnemonic tool called CH2OPD2 (community, home, hobbies, occupation/school, personal habits, diet and drugs). While almost 91% of residents always or usually asked about exposures from personal habits, more than 86% never or only occasionally asked about exposures in the community and more than 77% never or only occasionally asked about school-based exposures.
Additionally, residents were asked how often they asked patients about several clinically relevant sources of environmental exposure. The survey indicated that
- more than 62% of residents usually or always discussed sun exposure,
- almost 90% said they never discussed radon,
- almost 88% said they never or only occasionally discussed outdoor air pollution, and
- more than 84% said they never or only occasionally discussed exposure to mold.
Similarly, most residents (79.4%) reported they were very or quite confident answering patients' questions about sun exposure, but more than 63% were not at all confident answering questions about radon, and nearly 45% were not at all confident responding to questions about pesticides.
To measure knowledge of environmental health, residents were asked to match sources of exposure with certain diseases. Sources and diseases were grouped in sets of four, which meant that residents automatically had a 25% chance of guessing correctly.
While almost 83% of residents correctly identified recreational water use as a cause of gastroenteritis, only about 60% knew that radon was a cause of lung cancer and less than 60% knew that lead exposure could cause neurodevelopmental problems in children, even though residents listed lead highest among environmental exposures they would discuss with prospective patients. Less than 40% of residents knew that ground-level ozone could trigger an asthma attack.
Residents also answered an open-ended question about environmental exposures they considered important to discuss with prospective patients. Lead, cigarette smoke and the sun were the three most frequently cited exposures.
Regarding clinical practices, residents who thought their clinical supervisors had a moderate or very good understanding of environmental exposure were 85% more likely to take exposure histories in patients with uncontrolled asthma. Conversely, residents who perceived their supervisor's understanding of environmental health as poor were 85% less likely to take an exposure history in a patient with a history of recurrent miscarriage.
When asked which sources they relied on to answer clinical questions about environmental exposure hazards, more than 90% of residents reported using the Internet and more than 60% reported asking their clinical supervisor. This finding was noteworthy considering that less than 11% of residents thought their clinical supervisors understood environmental exposures quite well or very well.
Implications in the United States
"This study confirms previous findings that although environmental health is considered important by concerned family physicians in training, there is a gap between its perceived value and the knowledge, effective teaching and clinical practices necessary for diagnosing exposure-related conditions," the researchers concluded.
The authors focused on use of the environmental exposure history, which they called "a key clinical skill that should be addressed in resident and faculty education." They emphasized the importance of the exposure history as a core skill for family medicine residents. Given the relationship between the environment and public health, they also recommended that environmental health be made a high priority for inclusion in postgraduate family medicine education.
Regarding whether the results of this survey are generalizable to U.S. family medicine residents, Karen Mitchell, M.D., director of the AAFP's Division of Medical Education, offered a primer on how family medicine residents in the United States learn about environmental health.
"Environmental health is required for family medicine residents per the requirements for family medicine residency," Mitchell explained to AAFP News. She referred to the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine,(www.acgme.org) which state that residents must demonstrate competence to independently "assess community, environmental, and family influences on the health of patients," although programs vary in how they choose to teach this to residents.
Mitchell added that the AAFP disseminates residency program curriculum guidelines that incorporate environmental health into resident training, including occupational medicine, care of infants and children, and allergy and immunology.
In addition, Mitchell noted a collaboration between the Association of Family Medicine Residency Directors and the Society of Teachers of Family Medicine called the Family Medicine Residency Curriculum Resource,(www.fammedrcr.com) a subscription service that offers peer-reviewed, competency-based curriculum content, as well as presentations, quizzes and program facilitator guides. According to Mitchell, several resource curricula include environmental health content.
Related AAFP News Coverage
In the Trenches: Protecting the Environment, Our Health