Development and Implementation of a Medical School Course Integrating Basic, Clinical, and Health Systems Sciences.

OBJECTIVE: In recent years, significant steps have been made in integrating basic science and clinical medicine. There remains a gap in adding the third pillar of education: health systems science (HSS). Core clerkships represent an ideal learning venue to integrate all three. Students can experience the value of integrating basic science as they learn clinical medicine in environments where HSS is occurring all around them. METHODS: We outline the creation of Sciences and Art of Medicine Integrated (SAMI), a course that runs parallel with the clerkship year and integrates basic science and HSS with clinical medicine. A complete description of the planning and implementation of SAMI is provided. We include the participants and educational setting, the goals and objectives, and the structure of each session. To encourage the integration of basic science, HSS, and clinical medicine, students utilize a series of tools, described in detail. Examples of each tool are provided utilizing a case of a patient presenting with obstructive sleep apnea. RESULTS: We successfully implemented this course with positive reception from students. CONCLUSION: This course represents a step not only toward the integration of HSS with basic science and clinical medicine but also an advancement in training future clinicians to provide high-value care. Future curricular development must consider the validation of a measure of clinical reasoning that assesses a student's ability to think in a cognitively integrated fashion about basic science, HSS, and clinical medicine demonstrated by enhanced justification of clinical reasoning and a more holistic approach to planning patient care.

Mapping Mobility: Utilizing Local-Knowledge-Derived Activity Space to Estimate Exposure to Ambient Air Pollution among Individuals Experiencing Unsheltered Homelessness.

Individuals experiencing homelessness represent a growing population in the United States. Air pollution exposure among individuals experiencing homelessness has not been quantified. Utilizing local knowledge mapping, we generated activity spaces for 62 individuals experiencing homelessness residing in a semi-rural county within the United States. Satellite derived measurements of fine particulate matter (PM2.5) were utilized to estimate annual exposure to air pollution experienced by our participants, as well as differences in the variation in estimated PM2.5 at the local scale compared with stationary monitor data and point location estimates for the same period. Spatial variation in exposure to PM2.5 was detected between participants at both the point and activity space level. Among all participants, annual median PM2.5 exposure was 16.22 µg/m3, exceeding the National Air Quality Standard. Local knowledge mapping represents a novel mechanism to capture mobility patterns and investigate exposure to air pollution within vulnerable populations. Reliance on stationary monitor data to estimate air pollution exposure may lead to exposure misclassification, particularly in rural and semirural regions where monitoring is limited.

Developing a Problem-Based Learning Approach to the Integration of Environmental and Occupational Health Topics into Medical School Curriculum.

OBJECTIVES: A pilot study incorporating environmental and occupational health (EOH) learning objectives into medical school curriculum using problem-based learning approach. METHODS: One hundred eight-four Case Western Reserve University medical students participated in problem-based learning curriculum emphasizing EOH topics. Multiple choice (MCQ), short essay (SEQ), and summative short essay (SSEQ) questions assessed student knowledge. Two rating scale questions and one open-ended question determined student attitudes and confidence. RESULTS: Eighty percent of students answered 10 of 12 MCQs correctly. Students scored 70% on three of four SEQs and averaged 95.2% and 88.5% on two final SSEQs demonstrating improvement in student knowledge. Students rated the importance of and confidence in EOH topics as 4.4 and 3.9, respectively. CONCLUSION: Problem-based learning facilitated inclusion of new EOH content in pre-clerkship curriculum leading to achievement of students' cognitive objectives, positive attitudes, and improved confidence in EOH topics.

Renewable energy and occupational health and safety research directions: a white paper from the Energy Summit, Denver Colorado, April 11-13, 2011.

Renewable energy production may offer advantages to human health by way of less pollution and fewer climate-change associated ill-health effects. Limited data suggests that renewable energy will also offer benefits to workers in the form of reduced occupational injury, illness and deaths. However, studies of worker safety and health in the industry are limited. The Mountain and Plains Education and Research Center (MAP ERC) Energy Summit held in April 2011 explored issues concerning worker health and safety in the renewable energy industry. The limited information on hazards of working in the renewable energy industry emphasizes the need for further research. Two basic approaches to guiding both prevention and future research should include: (1) applying lessons learned from other fields of occupational safety and health, particularly the extractive energy industry; and (2) utilizing knowledge of occupational hazards of specific materials and processes used in the renewable energy industry.

Exposure registries: overview and utility for nanomaterial workers.

OBJECTIVE: This article provides the background for consideration of exposure registries to address potential disease risks in nanomaterial workers. METHODS: The history of exposure registries is reviewed with a focus on their purpose and criteria for establishment. RESULTS: A rationale is presented for developing registries of nanomaterial workers, and unresolved obstacles and challenges are identified. These include issues on inclusion criteria, funding, potential for legal risks, access to data, confidentiality of business information, privacy, and workers' expectations. CONCLUSION: If society is to gain the benefits from nanotechnology, it must take precautions and demonstrate care for those, such as workers, who may be most at risk of adverse effects. Establishing exposure registries is a part of such a precautionary and caring approach.

Occupational injury mortality: New Mexico 1998-2002.

BACKGROUND: The current study characterizes patterns of occupational injury fatalities in New Mexico for the 5-year period 1998-2002. METHODS: The study applied methods developed by the Council of State and Territorial Epidemiologists/National Institute for Occupational Safety and Health (CSTE/NIOSH) Occupational Health Indicator Work Group and compared the relative strength and weakness of two different datasets (CFOI and NMVRHS) for occupational injury fatality surveillance. RESULTS: Annual occupational injury mortality rates ranged from 4.4 to 7.6 per 100,000 employed persons aged 16 and over compared to annual US rates of 4.0-4.6 per 100,000. Risk factors for higher mortality rates included age over 65 years, self-employment, non-US citizenship, being African-American or Hispanic, and occurrence in rural counties. The top industry for fatality rate was mining followed by transportation, public utilities, agriculture, and construction. CONCLUSIONS: Applying CSTE/NIOSH Occupational Health Indicator protocol and using both CFOI and NMVRHS data improved the characterization of occupational injury mortality and the setting of priorities for prevention intervention.

A model for physician education and consultation in pediatric environmental health--the Pediatric Environmental Health Specialty Units (PEHSU) program.

The unique biologic characteristics and behaviors of children make them vulnerable to environmental toxicants. Physicians and other health professionals are challenged in addressing pediatric environmental health care needs in part because of deficient knowledge and skills in pediatric environmental health. This deficiency seems to stem from inadequate exposure to the field of pediatric environmental health during clinical training. The foundational goal of the PEHSU program is to address the gap in pediatric environmental health knowledge by enhancing the fundamental knowledge and skills of pediatricians, primary care physicians, and other health professionals.

Computer-based training for safety: comparing methods with older and younger workers.

INTRODUCTION: Computer-based safety training is becoming more common and is being delivered to an increasingly aging workforce. Aging results in a number of changes that make it more difficult to learn from certain types of computer-based training. Instructional designs derived from cognitive learning theories may overcome some of these difficulties. METHODS: Three versions of computer-based respiratory safety training were shown to older and younger workers who then took a high and a low level learning test. RESULTS: Younger workers did better overall. Both older and younger workers did best with the version containing text with pictures and audio narration. DISCUSSION: Computer-based training with pictures and audio narration may be beneficial for workers over 45 years of age. IMPACT ON INDUSTRY: Computer-based safety training has advantages but workers of different ages may benefit differently. Computer-based safety programs should be designed and selected based on their ability to effectively train older as well as younger learners.

Multimedia for occupational safety and health training: a pilot study examining a multimedia learning theory.

Occupational diseases are a significant problem affecting public health. Safety training is an important method of preventing occupational illness. Training is increasingly being delivered by computer although theories of learning from computer-based multimedia have been tested almost entirely on college students. This study was designed to determine whether these theories might also be applied to safety training applications for working adults. Participants viewed either computer-based multimedia respirator use training with concurrent narration, narration prior to the animation, or unrelated safety training. Participants then took a five-item transfer test which measured their ability to use their knowledge in new and creative ways. Participants who viewed the computer-based multimedia trainings both did significantly better than the control group on the transfer test. The results of this pilot study suggest that design guidelines developed for younger learners may be effective for training workers in occupational safety and health although more investigation is needed.

Silica exposure and systemic vasculitis.

Work in Department of Energy (DOE) facilities has exposed workers to multiple toxic agents leading to acute and chronic diseases. Many exposures were common to numerous work sites. Exposure to crystalline silica was primarily restricted to a few facilities. I present the case of a 63-year-old male who worked in DOE facilities for 30 years as a weapons testing technician. In addition to silica, other workplace exposures included beryllium, various solvents and heavy metals, depleted uranium, and ionizing radiation. In 1989 a painful macular skin lesion was biopsied and diagnosed as leukocytoclastic vasculitis. By 1992 he developed gross hematuria and dyspnea. Blood laboratory results revealed a serum creatinine concentration of 2.1 mg/dL, ethrythrocyte sedimentation rate of 61 mm/hr, negative cANCA (antineutrophil cytoplasmic antibody cytoplasmic pattern), positive pANCA (ANCA perinuclear pattern), and antiglomerular basement membrane negative. Renal biopsy showed proliferative (crescentric) and necrotizing glomerulonephritis. The patient's diagnoses included microscopic polyangiitis, systemic necrotizing vasculitis, leukocytoclastic vasculitis, and glomerulonephritis. Environmental triggers are thought to play a role in the development of an idiopathic expression of systemic autoimmune disease. Crystalline silica exposure has been linked to rheumatoid arthritis, scleroderma, systemic lupus erythematosus, rapidly progressive glomerulonephritis and some of the small vessel vasculitides. DOE workers are currently able to apply for compensation under the federal Energy Employees Occupational Illness Compensation Program (EEOICP). However, the only diseases covered by EEOICP are cancers related to radiation exposure, chronic beryllium disease, and chronic silicosis.