Hazardous Omissions: Investigating the Lack of Environmental Health Education in Medical Training

Hazardous Omissions: Investigating the Lack of Environmental Health Education in Medical Training | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hazardous Omissions: Investigating the Lack of Environmental Health Education in Medical Training Emma L. Cowles, Leon Z. Liu, Lauren Fine This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6420340/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Environmental health (EH) is a critical aspect of public health. Exposures contribute significantly to health outcomes such as respiratory diseases, cardiovascular conditions, and cancers. Given this impact, there is a growing recognition of the need to integrate EH content into medical education. Additionally, many students use third-party resources to supplement their school’s curricula. However, there is little data assessing EH content in commonly used resources. Methods: A survey was sent to second, third-, and fourth-year students at Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD) via email. This survey presented two clinical vignettes regarding EH and inquired about attitudes about its incorporation into formal curricula. Results were analyzed for trends amongst correctness, students’ desired specialties, and third-party resource use. Third-party resources were also analyzed for EH content. Results: Students performed poorly on the practice vignettes, demonstrating a lack of fundamental EH knowledge. Most were in support of EH being taught in their curriculum. There is also a significant reliance on third-party resources which have significant gaps in EH content. Discussion: Results reveal that NSU MD's curriculum and third-party resources fall short in covering EH topics. Survey results suggest that students value EH education and believe it should be included in their training. The reliance on third-party resources also highlights the need for better integration of EH content in both core curricula and supplemental materials. Addressing this gap is crucial to preparing future physicians to manage the environmental determinants of health effectively. Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Environmental health, defined as the study of how environmental factors impact human health and well-being, is a critical aspect of public health [1]. Environmental exposures throughout air, water, soil and food are known to contribute significantly to a variety of health outcomes such as respiratory diseases, cardiovascular conditions, and cancers [2,3]. Given the profound impact of environmental factors on health, there is a growing recognition of the need to integrate environmental health education into medical education [4]. Ninety-one percent of physicians express a need to learn more about environmental medicine topics yet only 13% report prior training in environmental history taking [5] This data suggests a gap between the education physicians want and the content that medical schools teach. Additionally, many students use third-party resources to supplement their school’s curriculum [6]. However, there is little data assessing environmental health content in the most frequently used resources. If students are neither receiving this content in their curriculum nor in supplemental information, it is likely that our future physicians are not prepared to address the impact of the environment on health in their future BACKGROUND Environmentally acquired illness is a serious health crisis, representing 24% of all global deaths [ 7 ]. It is thus important for physicians to both prevent and identify such illnesses early in their disease course as environmental exposures can have both immediate and long-term health effects. Air pollution has been linked to exacerbations of asthma while long-term exposure can contribute to the development of lung cancer. Similarly, exposure to hazardous chemicals, whether occupational or environmental, can lead to acute poisoning and long-term health effects [ 8 ]. Understanding the common health manifestations of major toxic exposures can help physicians better identify certain conditions and there is an understandable pressure for physicians to do so [ 9 ]. Yet, there is a noted lack of environmental health education in medical schools; in 2022 just 71 medical schools reported including environmental health education in their curriculum [ 10 ]. In instances where the current curriculum does not satisfy students, studies estimate up to 83% will supplement with third-party resources [ 11 ]. Such resources include a variety of online references, downloaded videos, question banks, and more that seek to reinforce nationally required undergraduate medical education material [ 12 ]. Given the gap that exists between physicians who want to know more about environmental health and a lack of medical education about environmental health, third-party resources could be an effective means to bridge this gap. Yet, to our knowledge, there is no data evaluating environmental health content in these third-party resources. MATERIALS AND METHODS A survey was sent to second, third-, and fourth-year students at Nova Southeastern University Dr. Kiran C Patel College of Allopathic Medicine (NSUMD) via email. The survey included two clinical vignettes that assessed students’ knowledge of environmental health topics, their attitudes about implementing this into formal medical curriculum, their intended medical specialties, and the third-party resources used. A review of 3rd party study resources commonly used by medical school students for Step 1 preparation was concurrently conducted. These resources include First Aid, Amboss, USMLE-Rx Bricks, Boards and Beyond (B&B), and Osmosis. Specifically, keywords such as ‘climate,’ ‘environment,’ ‘pollution,’ ‘exposure,’ ‘natural disaster’, and ‘natural resource’ were employed for the search criteria. Search results were then examined to assess the quality and depth of the content. Alternative wording for terms were also used as part of the criteria for thoroughness, such as ‘nature’ along with ‘natural.’ Singular and plural versions of ‘exposure,’ ‘natural disaster,’ and ‘natural resource’ were also assessed. Of the commercial resources that were analyzed, First Aid is delivered in a prep-book format, USMLE-Rx Bricks and Amboss as a collection of articles, and B&B and Osmosis as a series of videos organized into systems-based groups. Due to the diverse teaching methods used by the commercial resources that were analyzed, the keywords were applied in modified ways. In particular, the content search was implemented across all mentions in First Aid, by topic in USMLE-Rx Bricks and Amboss, and by video title for B&B and Osmosis. For First Aid, the keywords were searched across the entire text. All mentions of the specific keywords were recorded and analyzed for context. Additionally, the index was examined for any additional terms that may be relevant to environmental health and awareness. Non-environmental uses of keywords were omitted from the analysis, e.g. ‘hypersensitivity reaction due to antigen exposure’ was not recorded under the keyword ‘exposure.’ Redundancy of keyword usage was also accounted for. Related topics were also searched for, and two video results were examined: “Public Health” and “Quality and Safety.” For USMLE-Rx and Amboss, the keyword search was applied across the entire library of articles, with similar terms and topics automatically included as part of the search query. Due to the video format of B&B and Osmosis, the keywords were only applied to the titles of the videos. Additional mentions of keywords and topics in the videos were not recorded if they were not mentioned in the title. RESULTS Survey results indicate that students believe it is important to teach environmental health in medical school and that it is not currently included in their curriculum. Additionally, there was no significant difference in correctness in answering the vignette questions between those students who use the NSU MD curriculum and those who use third-party resources. Third-party content review revealed several areas of content gaps regarding specific aspects of environmental health in each resource. Chart 1: Student beliefs and perspectives about environmental health and its incorporation in the NSUMD curriculum. Table 1: Correctness of responses from survey vignettes, organized by the study materials used (NSU MD didactic curriculum and third-party resources). Chart 2: Results demonstrate the third-party study materials used by students surveyed. Table 2: Content search results for keywords across all four third-party resources. Climate Environment Pollution Exposure Natural (disaster) (Natural) resources Other related keywords First Aid, 2024 0 4 3 22 0 0 0 Amboss 0 6 6 63 0 0 0 USMLE Rx Bricks 5 5 1 0 1 2 0 Boards & Beyond 0 0 0 0 0 0 2 Osmosis 0 2 2 0 0 0 0 DISCUSSION Survey Survey results indicate that students believe it is important to teach environmental health in medical school and that understanding the impact of environmental exposures on health will be important in their future careers. However, students do not feel that their school’s curriculum includes information on how environmental exposures impact health, and they do not feel confident applying their knowledge of environmental exposures to clinical encounters or reasoning. This speaks to a gap in the education students want and the education they are receiving. Additionally, correctness of the vignette-based questions was not impacted by reliance on their school’s curriculum versus third-party resources. This may suggest that neither the school curricula nor third-party resources are more effective for teaching students about environmental health. Additionally, the overwhelming majority of students supplement their education with third-party resources, identifying a strong reliance on these resources and the importance of ensuring the gaps in these resources are also addressed. Content Review The content review conducted as part of this study indicated a considerable underemphasis on environmental health topics. The quality and depth of each topic was examined. First Aid had the highest number of mentions of the keywords, but rarely offered a thorough explanation of pathophysiology. Amboss offered a total of 75 articles related to the search terms, however these were largely focused on etiology of disease and there was very little information regarding how climate impacts health. Redundant mentions of the same keywords were included and counted under their respective articles. USMLE Rx Bricks offered a total of 14 detailed articles spread across many of the categories and each article was thoroughly explained. B&B and Osmosis both offered very few videos that pertained to the keywords. Limitations The study is limited by its small sample size. NSU MD has smaller class sizes than most other medical schools, so fewer students were available to respond to the survey. Most of the surveyed students were also currently in their second year, which may have led to underreporting of environmental health knowledge third- and fourth-year students gain through clinical rotations. Students responded to the survey voluntarily, which may add an element of bias. Additionally, as a cross-sectional study, temporality cannot be established. CONCLUSION This project highlights the insufficient focus on environmental health education within the NSU MD curriculum, a trend that is consistent across the majority of other medical school programs. It also emphasizes the lack of such education in third-party resources commonly used by medical students, altogether leading to poor performance on clinical questions involving environmental health. The reliance on third-party resources, which contain many gaps in environmental health content, also highlights the need for better integration of such information in both core curricula and supplemental materials. Given the high prevalence of environmental health-related illnesses in clinical practice, addressing this gap is crucial to preparing future physicians to manage the environmental determinants of health effectively. Declarations Ethical Approval, Consent to Publish, and Author Contribution : No funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Emma Cowles, Leon Liu, and Lauren Fine contributed to the study conception and design. All authors give consent for publication of this work. The need for ethics approval was reviewed by the Nova Southeastern University IRB and the study was approved under Exempt Category #1 as the survey constituted education pooling of MD students. IRB (2024-396). The need for informed consent was waived by the Nova Southeastern University IRB under Exempt Category #1. This study adhered to the Declaration of Helsinki. Material preparation, data collection and analysis were performed by Emma Cowles and Leon Liu. All authors read and approved the final manuscript. Author Contribution No funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Emma Cowles, Leon Liu, and Lauren Fine contributed to the study conception and design. All authors give consent for publication of this work. This study was granted exemption by the Nova Southeastern University IRB (2024-396). Material preparation, data collection and analysis were performed by Emma Cowles and Leon Liu. All authors read and approved the final manuscript. Data Availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. References American Public Health Association. Environmental Health. APHA. https://apha.org/topics-and-issues/environmental-health . Accessed November 6, 2024. Office of Disease Prevention and Health Promotion. Environmental Health. Healthy People 2030. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/environmental-health . Accessed November 6, 2024. Lavezzi AM, Ramos-Molina B. Environmental Exposure Science and Human Health. Int J Environ Res Public Health. 2023;20(10):5764. 10.3390/ijerph20105764 . Published 2023 May 9. Institute of Medicine (US) Committee on Curriculum Development in Environmental Medicine. In: Pope AM, Rall DP, editors. Environmental Medicine: Integrating a Missing Element into Medical Education. Washington (DC): National Academies Press (US); 1995. Trasande L, Schapiro ML, Falk R, et al. Pediatrician attitudes, clinical activities, and knowledge of environmental health in Wisconsin. WMJ. 2006;105(2):45–9. Lawrence ECN, Dine CJ, Kogan JR. Preclerkship Medical Students' Use of Third-Party Learning Resources. JAMA Netw Open. 2023;6(12):e2345971. 10.1001/jamanetworkopen.2023.45971 . Published 2023 Dec 1. Prüss-Ustün A, Wolf J, Corvalán C, Neville T, Bos R, Neira M. Diseases due to unhealthy environments: an updated estimate of the global burden of disease attributable to environmental determinants of health. J Public Health (Oxf). 2017;39(3):464–75. 10.1093/pubmed/fdw085 . Brusseau ML, Ramirez-Andreotta M, Pepper IL, Maximillian J. Environmental Impacts on Human Health and Well-Being. In: Brusseau ML, Pepper IL, Gerba CP, editors. Environmental and Pollution Science. 3rd ed. Academic; 2019. pp. 477–99. 10.1016/B978-0-12-814719-1.00026-4 . Vandenberg LN, Rayasam SDG, Axelrad DA, et al. Addressing systemic problems with exposure assessments to protect the public’s health. Environ Health. 2023;21(1):121. https://doi.org/10.1186/s12940-022-00917-0 . Association of American Medical Colleges. Medical schools including topics related to climate change in the curriculum. AAMC. Accessed November 6. 2024. https://www.aamc.org/data-reports/curriculum-reports/data/medical-schools-including-topics-related-climate-change-curriculum Lawrence ECN, Dine CJ, Kogan JR. Preclerkship Medical Students' Use of Third-Party Learning Resources. JAMA Netw Open. 2023;6(12):e2345971. 10.1001/jamanetworkopen.2023.45971 . Published 2023 Dec 1. Halperin SJ, Zhu JR, Francis JS, Grauer JN. Are Medical School Curricula Adapting With Their Students? A Survey on How Medical Students Study and How it Relates to USMLE Step 1 Scores. J Med Educ Curric Dev. 2024;11:23821205241228455. 10.1177/23821205241228455 . Published 2024 Jan 23. Chart Chart 1 and 2 are available in the Supplementary Files section. Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files floatimage4.png Chart 1: Student beliefs and perspectives about environmental health and its incorporation in the NSUMD curriculum. floatimage6.png Chart 2: Results demonstrate the third-party study materials used by students surveyed. floatimage5.jpeg Table 1: Correctness of responses from survey vignettes, organized by the study materials used (NSU MD didactic curriculum and third-party resources). 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Environmental exposures throughout air, water, soil and food are known to contribute significantly to a variety of health outcomes such as respiratory diseases, cardiovascular conditions, and cancers [2,3]. Given the profound impact of environmental factors on health, there is a growing recognition of the need to integrate environmental health education into medical education [4]. Ninety-one percent of physicians express a need to learn more about environmental medicine topics yet only 13% report prior training in environmental history taking [5] This data suggests a gap between the education physicians want and the content that medical schools teach. Additionally, many students use third-party resources to supplement their school\u0026rsquo;s curriculum [6]. However, there is little data assessing environmental health content in the most frequently used resources. If students are neither receiving this content in their curriculum nor in supplemental information, it is likely that our future physicians are not prepared to address the impact of the environment on health in their future\u003c/p\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eEnvironmentally acquired illness is a serious health crisis, representing 24% of all global deaths [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is thus important for physicians to both prevent and identify such illnesses early in their disease course as environmental exposures can have both immediate and long-term health effects. Air pollution has been linked to exacerbations of asthma while long-term exposure can contribute to the development of lung cancer. Similarly, exposure to hazardous chemicals, whether occupational or environmental, can lead to acute poisoning and long-term health effects [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnderstanding the common health manifestations of major toxic exposures can help physicians better identify certain conditions and there is an understandable pressure for physicians to do so [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Yet, there is a noted lack of environmental health education in medical schools; in 2022 just 71 medical schools reported including environmental health education in their curriculum [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In instances where the current curriculum does not satisfy students, studies estimate up to 83% will supplement with third-party resources [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Such resources include a variety of online references, downloaded videos, question banks, and more that seek to reinforce nationally required undergraduate medical education material [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Given the gap that exists between physicians who want to know more about environmental health and a lack of medical education about environmental health, third-party resources could be an effective means to bridge this gap. Yet, to our knowledge, there is no data evaluating environmental health content in these third-party resources.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eA survey was sent to second, third-, and fourth-year students at Nova Southeastern University Dr. Kiran C Patel College of Allopathic Medicine (NSUMD) via email. The survey included two clinical vignettes that assessed students\u0026rsquo; knowledge of environmental health topics, their attitudes about implementing this into formal medical curriculum, their intended medical specialties, and the third-party resources used.\u003c/p\u003e \u003cp\u003eA review of 3rd party study resources commonly used by medical school students for Step 1 preparation was concurrently conducted. These resources include First Aid, Amboss, USMLE-Rx Bricks, Boards and Beyond (B\u0026amp;B), and Osmosis. Specifically, keywords such as \u0026lsquo;climate,\u0026rsquo; \u0026lsquo;environment,\u0026rsquo; \u0026lsquo;pollution,\u0026rsquo; \u0026lsquo;exposure,\u0026rsquo; \u0026lsquo;natural disaster\u0026rsquo;, and \u0026lsquo;natural resource\u0026rsquo; were employed for the search criteria. Search results were then examined to assess the quality and depth of the content. Alternative wording for terms were also used as part of the criteria for thoroughness, such as \u0026lsquo;nature\u0026rsquo; along with \u0026lsquo;natural.\u0026rsquo; Singular and plural versions of \u0026lsquo;exposure,\u0026rsquo; \u0026lsquo;natural disaster,\u0026rsquo; and \u0026lsquo;natural resource\u0026rsquo; were also assessed.\u003c/p\u003e \u003cp\u003eOf the commercial resources that were analyzed, First Aid is delivered in a prep-book format, USMLE-Rx Bricks and Amboss as a collection of articles, and B\u0026amp;B and Osmosis as a series of videos organized into systems-based groups. Due to the diverse teaching methods used by the commercial resources that were analyzed, the keywords were applied in modified ways. In particular, the content search was implemented across all mentions in First Aid, by topic in USMLE-Rx Bricks and Amboss, and by video title for B\u0026amp;B and Osmosis.\u003c/p\u003e \u003cp\u003eFor First Aid, the keywords were searched across the entire text. All mentions of the specific keywords were recorded and analyzed for context. Additionally, the index was examined for any additional terms that may be relevant to environmental health and awareness. Non-environmental uses of keywords were omitted from the analysis, e.g. \u0026lsquo;hypersensitivity reaction due to antigen exposure\u0026rsquo; was not recorded under the keyword \u0026lsquo;exposure.\u0026rsquo; Redundancy of keyword usage was also accounted for. Related topics were also searched for, and two video results were examined: \u0026ldquo;Public Health\u0026rdquo; and \u0026ldquo;Quality and Safety.\u0026rdquo;\u003c/p\u003e \u003cp\u003eFor USMLE-Rx and Amboss, the keyword search was applied across the entire library of articles, with similar terms and topics automatically included as part of the search query.\u003c/p\u003e \u003cp\u003eDue to the video format of B\u0026amp;B and Osmosis, the keywords were only applied to the titles of the videos. Additional mentions of keywords and topics in the videos were not recorded if they were not mentioned in the title.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eSurvey results indicate that students believe it is important to teach environmental health in medical school and that it is not currently included in their curriculum. Additionally, there was no significant difference in correctness in answering the vignette questions between those students who use the NSU MD curriculum and those who use third-party resources. Third-party content review revealed several areas of content gaps regarding specific aspects of environmental health in each resource.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChart 1: Student beliefs and perspectives about environmental health and its incorporation in the NSUMD curriculum.\u003c/p\u003e\n\u003cp\u003eTable 1: Correctness of responses from survey vignettes, organized by the study materials used (NSU MD didactic curriculum and third-party resources).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChart 2: Results demonstrate the third-party study materials used by students surveyed.\u0026nbsp;\u003c/p\u003e\u003cp\u003eTable 2: Content search results for keywords across all four third-party resources.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003eClimate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3098%;\"\u003e\n \u003cp\u003eEnvironment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003ePollution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9428%;\"\u003e\n \u003cp\u003eExposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2896%;\"\u003e\n \u003cp\u003eNatural (disaster)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1313%;\"\u003e\n \u003cp\u003e(Natural) resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0034%;\"\u003e\n \u003cp\u003eOther related keywords\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003eFirst Aid, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3098%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9428%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2896%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1313%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0034%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003eAmboss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3098%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9428%;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2896%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1313%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0034%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003eUSMLE Rx Bricks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3098%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9428%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2896%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1313%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0034%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003eBoards \u0026amp; Beyond\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3098%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9428%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2896%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1313%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0034%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003eOsmosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3098%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7744%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9428%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2896%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1313%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0034%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurvey\u003c/h2\u003e \u003cp\u003eSurvey results indicate that students believe it is important to teach environmental health in medical school and that understanding the impact of environmental exposures on health will be important in their future careers. However, students do not feel that their school\u0026rsquo;s curriculum includes information on how environmental exposures impact health, and they do not feel confident applying their knowledge of environmental exposures to clinical encounters or reasoning. This speaks to a gap in the education students want and the education they are receiving. Additionally, correctness of the vignette-based questions was not impacted by reliance on their school\u0026rsquo;s curriculum versus third-party resources. This may suggest that neither the school curricula nor third-party resources are more effective for teaching students about environmental health. Additionally, the overwhelming majority of students supplement their education with third-party resources, identifying a strong reliance on these resources and the importance of ensuring the gaps in these resources are also addressed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eContent Review\u003c/h3\u003e\n\u003cp\u003eThe content review conducted as part of this study indicated a considerable underemphasis on environmental health topics. The quality and depth of each topic was examined. First Aid had the highest number of mentions of the keywords, but rarely offered a thorough explanation of pathophysiology. Amboss offered a total of 75 articles related to the search terms, however these were largely focused on etiology of disease and there was very little information regarding how climate impacts health. Redundant mentions of the same keywords were included and counted under their respective articles. USMLE Rx Bricks offered a total of 14 detailed articles spread across many of the categories and each article was thoroughly explained. B\u0026amp;B and Osmosis both offered very few videos that pertained to the keywords.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThe study is limited by its small sample size. NSU MD has smaller class sizes than most other medical schools, so fewer students were available to respond to the survey. Most of the surveyed students were also currently in their second year, which may have led to underreporting of environmental health knowledge third- and fourth-year students gain through clinical rotations.\u003c/p\u003e \u003cp\u003eStudents responded to the survey voluntarily, which may add an element of bias. Additionally, as a cross-sectional study, temporality cannot be established.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis project highlights the insufficient focus on environmental health education within the NSU MD curriculum, a trend that is consistent across the majority of other medical school programs. It also emphasizes the lack of such education in third-party resources commonly used by medical students, altogether leading to poor performance on clinical questions involving environmental health.\u003c/p\u003e \u003cp\u003eThe reliance on third-party resources, which contain many gaps in environmental health content, also highlights the need for better integration of such information in both core curricula and supplemental materials. Given the high prevalence of environmental health-related illnesses in clinical practice, addressing this gap is crucial to preparing future physicians to manage the environmental determinants of health effectively.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval, Consent to Publish, and Author Contribution\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Emma Cowles, Leon Liu, and Lauren Fine contributed to the study conception and design. All authors give consent for publication of this work.\u003c/p\u003e\n\u003cp\u003eThe need for ethics approval was reviewed by the Nova Southeastern University IRB and the study was approved under Exempt Category #1 as the survey constituted education pooling of MD students. IRB (2024-396). The need for informed consent was waived by the Nova Southeastern University IRB under Exempt Category #1.\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki. Material preparation, data collection and analysis were performed by Emma Cowles and Leon Liu. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNo funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Emma Cowles, Leon Liu, and Lauren Fine contributed to the study conception and design. All authors give consent for publication of this work. This study was granted exemption by the Nova Southeastern University IRB (2024-396). Material preparation, data collection and analysis were performed by Emma Cowles and Leon Liu. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Public Health Association. Environmental Health. APHA. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apha.org/topics-and-issues/environmental-health\u003c/span\u003e\u003cspan address=\"https://apha.org/topics-and-issues/environmental-health\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed November 6, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOffice of Disease Prevention and Health Promotion. Environmental Health. Healthy People 2030. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/environmental-health\u003c/span\u003e\u003cspan address=\"https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/environmental-health\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed November 6, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLavezzi AM, Ramos-Molina B. Environmental Exposure Science and Human Health. Int J Environ Res Public Health. 2023;20(10):5764. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph20105764\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20105764\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2023 May 9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute of Medicine (US) Committee on Curriculum Development in Environmental Medicine. In: Pope AM, Rall DP, editors. Environmental Medicine: Integrating a Missing Element into Medical Education. Washington (DC): National Academies Press (US); 1995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrasande L, Schapiro ML, Falk R, et al. Pediatrician attitudes, clinical activities, and knowledge of environmental health in Wisconsin. WMJ. 2006;105(2):45\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawrence ECN, Dine CJ, Kogan JR. Preclerkship Medical Students' Use of Third-Party Learning Resources. JAMA Netw Open. 2023;6(12):e2345971. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2023.45971\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2023.45971\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2023 Dec 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePr\u0026uuml;ss-Ust\u0026uuml;n A, Wolf J, Corval\u0026aacute;n C, Neville T, Bos R, Neira M. Diseases due to unhealthy environments: an updated estimate of the global burden of disease attributable to environmental determinants of health. J Public Health (Oxf). 2017;39(3):464\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/pubmed/fdw085\u003c/span\u003e\u003cspan address=\"10.1093/pubmed/fdw085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrusseau ML, Ramirez-Andreotta M, Pepper IL, Maximillian J. Environmental Impacts on Human Health and Well-Being. In: Brusseau ML, Pepper IL, Gerba CP, editors. Environmental and Pollution Science. 3rd ed. Academic; 2019. pp. 477\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/B978-0-12-814719-1.00026-4\u003c/span\u003e\u003cspan address=\"10.1016/B978-0-12-814719-1.00026-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandenberg LN, Rayasam SDG, Axelrad DA, et al. Addressing systemic problems with exposure assessments to protect the public\u0026rsquo;s health. Environ Health. 2023;21(1):121. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12940-022-00917-0\u003c/span\u003e\u003cspan address=\"10.1186/s12940-022-00917-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssociation of American Medical Colleges. Medical schools including topics related to climate change in the curriculum. AAMC. Accessed November 6. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aamc.org/data-reports/curriculum-reports/data/medical-schools-including-topics-related-climate-change-curriculum\u003c/span\u003e\u003cspan address=\"https://www.aamc.org/data-reports/curriculum-reports/data/medical-schools-including-topics-related-climate-change-curriculum\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawrence ECN, Dine CJ, Kogan JR. Preclerkship Medical Students' Use of Third-Party Learning Resources. JAMA Netw Open. 2023;6(12):e2345971. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2023.45971\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2023.45971\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2023 Dec 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalperin SJ, Zhu JR, Francis JS, Grauer JN. Are Medical School Curricula Adapting With Their Students? A Survey on How Medical Students Study and How it Relates to USMLE Step 1 Scores. J Med Educ Curric Dev. 2024;11:23821205241228455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/23821205241228455\u003c/span\u003e\u003cspan address=\"10.1177/23821205241228455\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2024 Jan 23.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Chart","content":"\u003cp\u003eChart 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6420340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6420340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Environmental health (EH) is a critical aspect of public health. Exposures contribute significantly to health outcomes such as respiratory diseases, cardiovascular conditions, and cancers. Given this impact, there is a growing recognition of the need to integrate EH content into medical education. Additionally, many students use third-party resources to supplement their school’s curricula. However, there is little data assessing EH content in commonly used resources.\u003c/p\u003e\n\u003cp\u003eMethods: A survey was sent to second, third-, and fourth-year students at Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD) via email. This survey presented two clinical vignettes regarding EH and inquired about attitudes about its incorporation into formal curricula. Results were analyzed for trends amongst correctness, students’ desired specialties, and third-party resource use. Third-party resources were also analyzed for EH content.\u003c/p\u003e\n\u003cp\u003eResults: Students performed poorly on the practice vignettes, demonstrating a lack of fundamental EH knowledge. Most were in support of EH being taught in their curriculum. There is also a significant reliance on third-party resources which have significant gaps in EH content.\u003c/p\u003e\n\u003cp\u003eDiscussion: Results reveal that NSU MD's curriculum and third-party resources fall short in covering EH topics. Survey results suggest that students value EH education and believe it should be included in their training. The reliance on third-party resources also highlights the need for better integration of EH content in both core curricula and supplemental materials. Addressing this gap is crucial to preparing future physicians to manage the environmental determinants of health effectively.\u003c/p\u003e","manuscriptTitle":"Hazardous Omissions: Investigating the Lack of Environmental Health Education in Medical Training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-04 11:30:18","doi":"10.21203/rs.3.rs-6420340/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c46196a-31f5-468b-9b32-f5467d23d2db","owner":[],"postedDate":"July 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-22T13:11:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-04 11:30:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6420340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6420340","identity":"rs-6420340","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}