Occupational and environmental medicine in the family medicine curriculum.

Abstract

To the Editor: The series of articles by Drs Schuman et al1-3 address an important issue in the training of family medicine (FM) doctors in occupational and environmental medicine (OEM). The teaching of OEM is variable in medical education throughout the world.4,5 In many countries, and OEM gap is apparent at both the undergraduate level in medical school, as well as the postgraduate level in FM training. We would like to share our experience on how this gap is bridged in Singapore. In the medical school in Singapore, both disciplines are taught primarily by the Department of Community, Occupational and Family Medicine. OEM training of medical undergraduates consists of a series of lectures based on an organ-systems approach. This is supplemented by small group tutorials on patients likely to be encountered in primary care and hospital practice, eg, those with contact dermatitis, anemia detected during pre-employment examination,6 and a visit to a workplace. One objective is to ensure that students are able to identify occupational factors in the causation of disease and recognize the need to consider occupational factors in the management of all patients. Another aim is for students to be aware of the importance of preventive measures for work-related illness and the promotion of health at work. The undergraduate FM curriculum includes formal teaching as well as practical training. In the practical training, there is a one-week posting to a family practice and another week at a government primary health care center. Cases seen during the postings are logged and discussed with the clinical tutor. In the teaching sessions, the impact of the work environment on disease etiology and management is discussed whenever relevant. At the postgraduate level, FM training is conducted by the School of Postgraduate Medical Studies of the university. In the curriculum, care of special groups of patients, including the worker, is specifically listed in the training requirements booklet. A module on OEM is mandatory in the training program. The OEM teaching, which is jointly given by OEM and FM physicians, includes slide quizzes on clinical cases seen in primary care practice. Subsequent discussion of these case studies centers around the clinical and OEM aspects. In addition, over 500 FM practitioners in the country (about one quarter of all FM practitioners) have undergone formal postgraduate training in OEM. This is because of a national statutory requirement for medical examinations among workers exposed to prescribed hazards (eg, noise, some heavy metals and chemicals). These FM practitioners have to complete an examinable 72-hour course in OEM successfully before they can register as Designated Factory Doctors (DFDs). In 1998, this course will be replaced with a 100-hour course leading to a postgraduate diploma in occupational medicine. Statutory medical examinations and certification for fitness to work in some occupations can only be performed by DFDs. As such, many employers prefer to appoint a DFD as their company contract doctor. While an OEM gap in medical and FM training may exist in many situations throughout the world, the experiences in South Carolina and in Singapore demonstrate that the problem is not insurmountable. An integrated clinical case-study approach in the training appears to be an effective way to reduce the OEM gap in primary care doctors. David Koh, MBBS, MSc, PhD Sin-Eng Chia, MBBS, MSc, MD Department of Community, Occupational and Family Medicine; Faculty of Medicine; National University of Singapore