Call to Action
ajog.org
Medical education for obstetricians and gynecologists should incorporate environmental health Veronica A. Tinney, MPH; Jerome A. Paulson, MD; Susanne L. Bathgate, MD; John W. Larsen, MD
E
xposure to environmental chemicals is ubiquitous in air, water, food consumption, and consumer products, and concern is growing over the long-term health impacts of repeated, low-dose exposure to environmental chemicals. National Health and Nutrition Examination Survey data demonstrate widespread exposure to environmental chemicals among pregnant women and women of childbearing age including heavy metals, volatile organic compounds, and endocrine disrupting chemicals.1 Many health outcomes have developmental origins, and exposures in utero can have permanent and irreversible impacts on health.2 For example, prenatal exposure to heavy metals, such as mercury, is well documented to cause adverse neurological effects in children3-5 and can occur through maternal consumption of fish high in methylmercury. Mercury exposure during pregnancy is particularly concerning because mercury is actively transported across the placenta, causing a higher dose to the fetus than the mother.6 Therefore, a mother may be asymptomatic, whereas the fetus sustains neurological damage.
THE PROBLEM: Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, medical education on environmental health is limited. A SOLUTION: Integrating environmental health topics into medical education can help ensure obstetricians-gynecologists are prepared to address patients’ concerns about environmental exposures on their health, fertility and pregnancy outcomes.
Prenatal exposure to pollutants such as arsenic, tobacco smoke, air pollution, and polycyclic aromatic hydrocarbons (PAHs) induce epigenetic dysregulation, creating heritable changes in phenotypes.7 Prenatal exposure to airborne PAHs, a group of chemicals that can be created through incomplete burning of fossil fuels, is associated with decreased birthweight and head circumference among African Americans.8 High levels of exposure to PAHs during the prenatal period is associated with lower cognitive development scores at 3 years of age9 and lesser intelligence quotient scores at the age of 5 years.10 By identifying hazardous environmental exposures during pregnancy, obstetricians-gynecologists can improve health over the life course.2
Environmental health has long been recognized to be of importance to pediatric practice. Although it certainly is critical for pediatricians to consider environmental health exposures, for many environmental exposures, diagnosis by a pediatrician is not timely enough to treat health outcomes resulting from exposures occurring during the prenatal period. An example is the current pediatric approach to lead poisoning. Lead has long been known to cross the placenta and impair neurodevelopment however; current practice is for pediatricians to screen children for elevated blood lead levels at 12 months of age. This method is reactionary rather than preventative because once lead exposure has occurred, the adverse neurological outcomes are
From the Mid-Atlantic Center for Children’s Health and the Environment, Child Health Advocacy Institute, Children’s National Health System (Ms Tinney and Dr Paulson); and Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Larsen and Bathgate). Received June 10, 2014; revised July 11, 2014; accepted July 22, 2014. This publication was supported by the cooperative agreement award number 1U61TS000118-05 from the Agency for Toxic Substances and Disease Registry (ATSDR). Its contents are the responsibility of the authors and do not necessarily represent the official views of the Agency for Toxic Substances and Disease Registry (ATSDR). The US Environmental Protection Agency (EPA) supports the Pediatric Environmental Health Specialty Unit (PEHSU) by providing funds to ATSDR under Inter- Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications. J.W.L. currently provides consultation to Procter and Gamble. J.A.P. has served as an expert witness in childhood lead poisoning cases for the following firms: Ashcraft & Gerel, LLP, Baltimore, MD; Law Offices of Peter T. Nicholl, Baltimore, MD; and the Law Office of Dmitry Khrizman, LLC, Baltimore, MD. He has served as an expert witness related to chemical management policy (The Toxic Substances Control Act) for Sullivan, Ward, Asher & Patton, PC, Southfield, MI. The other authors have nothing to report. Corresponding author: Veronica A. Tinney, MPH. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.07.038
FEBRUARY 2015 American Journal of Obstetrics & Gynecology
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Call to Action irreversible. Obstetricians-gynecologists can prevent lead poisoning in children by surveying patients during preconception and prenatal visits about potential lead exposures in their home, occupation, or cultural practices. Collaboration of pediatricians and obstetricians-gynecologists can lead to the identification of previously unknown environmental exposures. In a recent case study by Dickenson et al,11 the Pediatric Environmental Health Specialty Unit at the University of California, San Francisco assisted in identifying the source of an abnormally high mercury level in a pregnant woman as the use of an imported face cream containing mercury. The woman was identified as part of a study monitoring environmental exposures in pregnant women and demonstrates the necessity for the screening of heavy metals and environmental chemicals among women.11
The role of obstetriciansgynecologists Much of the population of reproductive age are unaware of the environmental chemicals they are exposed to daily where they live and work and the effects these exposures have on their fertility and health of future offspring. Obstetricians and gynecologists can help patients make informed decisions and take steps to reduce exposures affecting their reproductive health. Obstetriciansgynecologists have a critical and unique role to play, both in clinical care and in advocacy for federal policy reform. Clinical care. Obstetricians and gynecologists are increasingly confronted with clinical situations and questions from patients about the impact of environmental chemicals on their general health, fertility, and pregnancy outcome. Obstetricians-gynecologists are well positioned to provide guidance on environmental health issues to patients.12 Obstetricians-gynecologists can inquire about environmental exposures13 by asking questions about key exposures, such as mercury, lead, pesticides, and endocrine-disrupting chemicals.14 Sathyanarayana et al14
ajog.org published an article in the Journal that provides specific risk communication messaging, exposure reduction actions, and sample clinical questions for determining environmental exposures among patients. Despite the opportunity to educate patients on reducing environmental exposures, most obstetricians-gynecologists do not ask patients about environmental exposures aside from smoking, alcohol consumption, and nutrition.15 A recent survey of 2514 American Congress of Obstetricians and Gynecologists (ACOG) fellows reported that half of the obstetricians-gynecologists surveyed rarely conduct an environmental health history, despite the majority of respondents agreeing that an environmental health history would identify patient exposures (86%) and help prevent harmful exposures (80%).15 Reasons for not asking patients about environmental exposures included concern about creating unnecessary anxiety among patients, not possessing adequate information to answer patient questions, and the inability of patients to take steps to reduce exposures.15 Advocacy. Patient centered actions cannot reduce all exposure to environmental chemicals, and obstetricians-gynecologists can be influential advocates of environmentally safe policies.12,16 An example of an area in which obstetriciansgynecologists can advocate is for the strengthening of current regulatory oversight of industrial chemicals. Of the 80,000 industrial chemicals in commerce, the majority have little to no toxicity testing on their impacts on human health.17 Obstetricians and gynecologists can advocate for the development of robust screening regulations and make precautionary recommendations in the absence of complete data.18 Obstetricians-gynecologists can take a precautionary approach to addressing emerging environmental contaminants.4 The Precautionary Principle “provides justification for public policy actions in situations of scientific complexity, uncertainty, and ignorance, where there may be a need to act in order to avoid, or
164 American Journal of Obstetrics & Gynecology FEBRUARY 2015
reduce, potentially serious or irreversible threats to health or the environment.”19 Delaying action until research provides causal support for an associated environmental exposure and adverse health outcome may take decades, time in which adverse reproductive health outcomes can be avoided.19 This strategy is not meant to be alarmist; rather, obstetricians-gynecologists should exercise a degree of caution, to avoid delay in protecting patients, when the preponderance of evidence seems to be pointing toward the adverse reproductive health outcomes from chemicals ubiquitous in the environment. An example of an area in which the precautionary principle can be used is exposure to chemicals that influence the endocrine system. In standard toxicity testing, chemicals are tested to determine a threshold value, below which there are presumably no adverse health outcomes. Endocrine-disrupting chemicals have been shown to have nonmonotonic dose-response curves, wherein even low doses are capable of producing adverse health effects, and in some cases, more severe effects occur at low doses than higher doses.20 Standard toxicity testing also does not account for the unique exposures of pregnant women and children, exposure to multiple chemicals, and susceptible windows of development. As a result, the Endocrine Society has called for use of the precautionary principle for regulation of endocrine-disrupting chemicals.20 By utilizing the precautionary principle, obstetricians-gynecologists can address reproductive health concerns related to environmental exposures without causing unnecessary stress for their patients. Environmental health in obstetricsgynecology medical education. Recognition of environmental hazards among obstetricians-gynecologists has gained momentum with the release of the ACOG Committee on Health Care for Underserved Women and the American Society for Reproductive Medicine (ASRM) Practice Committee joint committee opinion 575.18 In the opinion, ACOG and ASRM urge
Call to Action
ajog.org clinicians to become knowledgeable on potential environmental exposures and to conduct environmental histories of patients during preconception and prenatal visits.18 The joint committee also published a longer, companion piece, which provides guidance to practitioners on specific issues, recommendations for prevention, and additional resources.21 The joint committee opinion demonstrates that reproductive health professionals can be advocates for protecting men, women, and their offspring from exposure to environmental hazards. Further to creating awareness, a formal mechanism to educate obstetricians-gynecologists on environmental health hazards is needed to ensure all trainees are prepared to address patients’ concerns. Over the course of 4 years of medical education, one study found the average number of hours required for environmental health was only 7 hours total.22 Obstetrics-gynecology education has been largely void of environmental health topics aside from nutrition, smoking, and drinking during pregnancy.12 Instruction on taking an environmental history is limited among obstetrics-gynecology medical programs22 with only 1 in 15 obstetricians-gynecologists reporting training specific to taking an environmental history.15 In response to this need, the MidAtlantic Center for Children’s Health and the Environment and the George Washington University Department of Obstetrics and Gynecology convened a meeting of faculty members and residents representing 16 academic medical programs of obstetrics-gynecology in the District of Columbia, Delaware, Maryland, Pennsylvania, Virginia, and West Virginia. The meeting promoted environmental health among the obstetrics and gynecology profession and sought to incorporate environmental health topics into graduate medical education. A work group of faculty members and residents was formed to continue the discussion beyond the meeting on how academic programs of obstetrics-gynecology can
integrate environmental health topics. The work group will identify mechanisms to incorporate environmental health topics, barriers that may exist, and the resources needed to successfully integrate environmental health topics into graduate medical education. Recommendation. Initial avenues identified by the work group for establishing formal training for obstetriciansgynecologists in environmental health include the following topics. Medical school curriculum. Integration of environmental health topics for medical education is necessary at all levels. Methods have been established to assist educational programming development, including integration of environmental health topics into basic science courses and the organ systems approach applied by many curriculums.23 Faculty members at the George Washington University Department of Obstetrics and Gynecology have started creating a medical school and residency curriculum on environmental health specifically for obstetriciansgynecologists. Clinical trainee programs. The University of California, San Francisco, Program on Reproductive Health and the Environment (PRHE) has an established program dedicated to creating awareness of environmental health among reproductive health professionals. The program includes a rotations program for obstetrics-gynecology clinical trainees and maternal-fetal medicine fellows. The PRHE has developed resources for reproductive health professionals, including patient educational materials and environmental health history forms for clinical practice (http://prhe. ucsf.edu/prhe/clinical_resources.html). Obstetrics and gynecology medical programs can use the PRHE as a model for integrating environmental health into fellowships and graduate medical education. Inclusion on resident training and board-certifying exams. Inclusion of environmental health questions on resident
training exams and board-certifying exams would prompt programs to include environmental health topics in their curriculum. The authors suggest that the Council on Residency Education in Obstetrics and Gynecology, the American Board of Obstetrics and Gynecology, and the American Osteopathic Board of Obstetrics and Gynecology consider including environmental health questions on their exams. Faculty training. Leaders in medical education and faculty members could be trained on reproductive environmental health through the Association of Professors of Gynecology and Obstetrics or by establishing environmental health faculty champions programs23 for obstetricians-gynecologists. Continuing education requirements. Requiring continuing education credits in environmental health would ensure that currently practicing obstetriciansgynecologists receive an introduction to environmental health topics. The Agency for Toxic Substances and Disease Registry has developed environmental medicine case studies available to all health professionals required to complete continuing education23 (www.atsdr. cdc.gov/emes/health_professionals/index. html).
Comment By providing obstetricians and gynecologists with the information needed about environmental health hazards, obstetricians and gynecologists can protect their patients, particularly women, at all stages of their lives from environmental hazards. Efforts are needed to support environmental health practice among obstetricians and gynecologists. Including obstetriciansgynecologists in the field of environmental health can assist in identifying new research questions and add perspective to broaden the field of environmental health. In light of the ACOG and ASRM joint committee opinion and the strengthening scientific evidence, it is hoped that the community of obstetrician-gynecology educators will
FEBRUARY 2015 American Journal of Obstetrics & Gynecology
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Call to Action respond with an expanded environmental health education. REFERENCES 1. Woodruff TJ, Zota AR, Schwartz JM. Environmental chemicals in pregnant women in the United States: NHANES 2003-2004. Environ Health Perspect 2011;119:878-85. 2. Newbold RR, Heindel JJ. Developmental exposures and implications for early and latent disease. In: Woodruff TJ, Janssen SJ, Guillette LJ, Guidice LC, eds. Environmental impacts on reproductive health and fertility. New York: Cambridge University Press; 2010:92-102. 3. Debes F, Budtz-Jørgensen E, Weihe P, et al. Impact of prenatal methylmercury exposure on neurobehavioral function at age 14 years. Neurotoxicol Teratol 2006;28:536-47. 4. Grandjean P, Weihe P, Nielsen F, et al. Neurobehavioral deficits at age 7 years associated with prenatal exposure to toxicants from maternal seafood diet. Neurotoxicol Teratol 2012;34:466-72. 5. Grandjean P, Weihe P, Debes F, Choi AL, Budtz-Jørgensen E. Neurotoxicity from prenatal and postnatal exposure to methylmercury. Neurotoxicol Teratol 2014;43:39-44. 6. Stern AH, Smith AE. An assessment of the cord blood: Maternal blood methylmercury ratio: Implications for risk assessment. Environ Health Perspect 2003;111:1465-70. 7. Perera F, Herbstman J. Prenatal environmental exposures, epigenetics, and disease. Reprod Toxicol 2011;31:363-73.
ajog.org 8. Perera FP, Rauh V, Tsai WY, et al. Effects of transplacental exposure to environmental pollutants on birth outcomes in a multiethnic population. Environ Health Perspect 2003;111: 201-5. 9. Perera FP, Rauh V, Whyatt RM, et al. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on neurodevelopment in the first 3 years of life among inner-city children. Environ Health Perspect 2006;114:1287-92. 10. Perera FP, Tang D, Wang S, et al. Prenatal polycyclic aromatic hydrocarbon (PAH) exposure and child behavior at age 6-7 years. Environ Health Perspect 2012;120:921-6. 11. Dickenson CA, Woodruff TJ, Stotland NE, et al. Elevated mercury levels in pregnant woman linked to skin cream from Mexico. Am J Obstet Gynecol 2013;209:e4-5. 12. Sutton P, Woodruff TJ, Perron J, et al. Toxic environmental chemicals: the role of reproductive health professionals in preventing harmful exposures. Am J Obstet Gynecol 2012;207: 164-73. 13. Woodruff TJ, Carlson A, Schwartz JM, et al. Proceedings of the summit on environmental challenges to reproductive health and fertility: executive summary. Fertil Steril 2008;89(2 Suppl):e1-20. 14. Sathyanarayana S, Focareta J, Dailey T, et al. Environmental exposures: how to counsel preconception and prenatal patients in the clinical setting. Am J Obstet Gynecol 2012;207: 463-70. 15. Stotland N, Sutton P, Trowbridge J, et al. Counseling patients on preventing prenatal environmental exposures—a mixed-methods
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study of obstetricians. PloS One 2014;9: e98771. 16. Schubert KG, Cavarocchi N. The value of advocacy in obstetrics and maternal-fetal medicine. Curr Opin Obstet Gynecol 2012;24:453-7. 17. Grandjean P, Landrigan PJ. Developmental neurotoxicity of industrial chemicals. Lancet 2006;368:2167-78. 18. American College of Obstetricians and Gynecologists. ACOG Committee Opinion no. 575. Exposure to toxic environmental agents. Fertil Steril 2013;100:931-4. 19. Gee GC, Payne-Sturges DC. Environmental health disparities: a framework integrating psychosocial and environmental concepts. Environ Health Perspect 2004;112:1645-53. 20. Diamanti-Kandarakis E, Bourguignon JP, Giudice LC, et al. Endocrine-disrupting chemicals: an endocrine society scientific statement. Endocr Rev 2009;30:293-342. 21. American College of Obstetricians and Gynecologists. Exposure to toxic environmental agents. Washington, DC: ACOG. 2013. Available at: http://www.acog.org/w/media/ Committee%20Opinions/Committee%20on% 20Health%20Care%20for%20Underserved% 20Women/ExposuretoToxic.pdf. Accessed July 11, 2014. 22. Schenk M, Popp SM, Neale AV, Demers RY. Environmental medicine content in medical school curricula. Acad Med 1996;71: 499-501. 23. Gehle KS, Crawford JL, Hatcher MT. Integrating environmental health into medical education. Am J Prev Med 2011;414(Suppl 3): S296-301.
Abstract for: Medical education for obstetricians and gynecologists should incorporate environmental health Veronica A. Tinney MPH; Jerome A. Paulson MD; Susanne L. Bathgate MD; John W. Larsen MD
Obstetricians-gynecologists can protect the reproductive health of women, men, and their offspring from environmental hazards through preconception and prenatal counseling and encouraging patients to take actions to reduce environmental exposures. Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, education on environmental health in medical education is limited. The MidAtlantic Center for Children’s Health and the Environment and the Department of Obstetrics and Gynecology of George Washington University convened a meeting to begin integration of environmental health topics into medical education for obstetriciansgynecologists. Several avenues were identified to incorporate environmental health topics into medical education including continuing education requirements, inclusion of environmental health questions on board certification examinations and the creation of a curriculum on environmental health specific to obstetrics-gynecology. Key words: environmental exposures, medical education, prevention
Vol. 212, No. 2, February 2015, page 163.e1
ajog.org
Medical education for obstetricians and gynecologists should incorporate environmental health Veronica A. Tinney, MPH; Jerome A. Paulson, MD; Susanne L. Bathgate, MD; John W. Larsen, MD
E
xposure to environmental chemicals is ubiquitous in air, water, food consumption, and consumer products, and concern is growing over the long-term health impacts of repeated, low-dose exposure to environmental chemicals. National Health and Nutrition Examination Survey data demonstrate widespread exposure to environmental chemicals among pregnant women and women of childbearing age including heavy metals, volatile organic compounds, and endocrine disrupting chemicals.1 Many health outcomes have developmental origins, and exposures in utero can have permanent and irreversible impacts on health.2 For example, prenatal exposure to heavy metals, such as mercury, is well documented to cause adverse neurological effects in children3-5 and can occur through maternal consumption of fish high in methylmercury. Mercury exposure during pregnancy is particularly concerning because mercury is actively transported across the placenta, causing a higher dose to the fetus than the mother.6 Therefore, a mother may be asymptomatic, whereas the fetus sustains neurological damage.
THE PROBLEM: Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, medical education on environmental health is limited. A SOLUTION: Integrating environmental health topics into medical education can help ensure obstetricians-gynecologists are prepared to address patients’ concerns about environmental exposures on their health, fertility and pregnancy outcomes.
Prenatal exposure to pollutants such as arsenic, tobacco smoke, air pollution, and polycyclic aromatic hydrocarbons (PAHs) induce epigenetic dysregulation, creating heritable changes in phenotypes.7 Prenatal exposure to airborne PAHs, a group of chemicals that can be created through incomplete burning of fossil fuels, is associated with decreased birthweight and head circumference among African Americans.8 High levels of exposure to PAHs during the prenatal period is associated with lower cognitive development scores at 3 years of age9 and lesser intelligence quotient scores at the age of 5 years.10 By identifying hazardous environmental exposures during pregnancy, obstetricians-gynecologists can improve health over the life course.2
Environmental health has long been recognized to be of importance to pediatric practice. Although it certainly is critical for pediatricians to consider environmental health exposures, for many environmental exposures, diagnosis by a pediatrician is not timely enough to treat health outcomes resulting from exposures occurring during the prenatal period. An example is the current pediatric approach to lead poisoning. Lead has long been known to cross the placenta and impair neurodevelopment however; current practice is for pediatricians to screen children for elevated blood lead levels at 12 months of age. This method is reactionary rather than preventative because once lead exposure has occurred, the adverse neurological outcomes are
From the Mid-Atlantic Center for Children’s Health and the Environment, Child Health Advocacy Institute, Children’s National Health System (Ms Tinney and Dr Paulson); and Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Larsen and Bathgate). Received June 10, 2014; revised July 11, 2014; accepted July 22, 2014. This publication was supported by the cooperative agreement award number 1U61TS000118-05 from the Agency for Toxic Substances and Disease Registry (ATSDR). Its contents are the responsibility of the authors and do not necessarily represent the official views of the Agency for Toxic Substances and Disease Registry (ATSDR). The US Environmental Protection Agency (EPA) supports the Pediatric Environmental Health Specialty Unit (PEHSU) by providing funds to ATSDR under Inter- Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications. J.W.L. currently provides consultation to Procter and Gamble. J.A.P. has served as an expert witness in childhood lead poisoning cases for the following firms: Ashcraft & Gerel, LLP, Baltimore, MD; Law Offices of Peter T. Nicholl, Baltimore, MD; and the Law Office of Dmitry Khrizman, LLC, Baltimore, MD. He has served as an expert witness related to chemical management policy (The Toxic Substances Control Act) for Sullivan, Ward, Asher & Patton, PC, Southfield, MI. The other authors have nothing to report. Corresponding author: Veronica A. Tinney, MPH. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.07.038
FEBRUARY 2015 American Journal of Obstetrics & Gynecology
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Call to Action irreversible. Obstetricians-gynecologists can prevent lead poisoning in children by surveying patients during preconception and prenatal visits about potential lead exposures in their home, occupation, or cultural practices. Collaboration of pediatricians and obstetricians-gynecologists can lead to the identification of previously unknown environmental exposures. In a recent case study by Dickenson et al,11 the Pediatric Environmental Health Specialty Unit at the University of California, San Francisco assisted in identifying the source of an abnormally high mercury level in a pregnant woman as the use of an imported face cream containing mercury. The woman was identified as part of a study monitoring environmental exposures in pregnant women and demonstrates the necessity for the screening of heavy metals and environmental chemicals among women.11
The role of obstetriciansgynecologists Much of the population of reproductive age are unaware of the environmental chemicals they are exposed to daily where they live and work and the effects these exposures have on their fertility and health of future offspring. Obstetricians and gynecologists can help patients make informed decisions and take steps to reduce exposures affecting their reproductive health. Obstetriciansgynecologists have a critical and unique role to play, both in clinical care and in advocacy for federal policy reform. Clinical care. Obstetricians and gynecologists are increasingly confronted with clinical situations and questions from patients about the impact of environmental chemicals on their general health, fertility, and pregnancy outcome. Obstetricians-gynecologists are well positioned to provide guidance on environmental health issues to patients.12 Obstetricians-gynecologists can inquire about environmental exposures13 by asking questions about key exposures, such as mercury, lead, pesticides, and endocrine-disrupting chemicals.14 Sathyanarayana et al14
ajog.org published an article in the Journal that provides specific risk communication messaging, exposure reduction actions, and sample clinical questions for determining environmental exposures among patients. Despite the opportunity to educate patients on reducing environmental exposures, most obstetricians-gynecologists do not ask patients about environmental exposures aside from smoking, alcohol consumption, and nutrition.15 A recent survey of 2514 American Congress of Obstetricians and Gynecologists (ACOG) fellows reported that half of the obstetricians-gynecologists surveyed rarely conduct an environmental health history, despite the majority of respondents agreeing that an environmental health history would identify patient exposures (86%) and help prevent harmful exposures (80%).15 Reasons for not asking patients about environmental exposures included concern about creating unnecessary anxiety among patients, not possessing adequate information to answer patient questions, and the inability of patients to take steps to reduce exposures.15 Advocacy. Patient centered actions cannot reduce all exposure to environmental chemicals, and obstetricians-gynecologists can be influential advocates of environmentally safe policies.12,16 An example of an area in which obstetriciansgynecologists can advocate is for the strengthening of current regulatory oversight of industrial chemicals. Of the 80,000 industrial chemicals in commerce, the majority have little to no toxicity testing on their impacts on human health.17 Obstetricians and gynecologists can advocate for the development of robust screening regulations and make precautionary recommendations in the absence of complete data.18 Obstetricians-gynecologists can take a precautionary approach to addressing emerging environmental contaminants.4 The Precautionary Principle “provides justification for public policy actions in situations of scientific complexity, uncertainty, and ignorance, where there may be a need to act in order to avoid, or
164 American Journal of Obstetrics & Gynecology FEBRUARY 2015
reduce, potentially serious or irreversible threats to health or the environment.”19 Delaying action until research provides causal support for an associated environmental exposure and adverse health outcome may take decades, time in which adverse reproductive health outcomes can be avoided.19 This strategy is not meant to be alarmist; rather, obstetricians-gynecologists should exercise a degree of caution, to avoid delay in protecting patients, when the preponderance of evidence seems to be pointing toward the adverse reproductive health outcomes from chemicals ubiquitous in the environment. An example of an area in which the precautionary principle can be used is exposure to chemicals that influence the endocrine system. In standard toxicity testing, chemicals are tested to determine a threshold value, below which there are presumably no adverse health outcomes. Endocrine-disrupting chemicals have been shown to have nonmonotonic dose-response curves, wherein even low doses are capable of producing adverse health effects, and in some cases, more severe effects occur at low doses than higher doses.20 Standard toxicity testing also does not account for the unique exposures of pregnant women and children, exposure to multiple chemicals, and susceptible windows of development. As a result, the Endocrine Society has called for use of the precautionary principle for regulation of endocrine-disrupting chemicals.20 By utilizing the precautionary principle, obstetricians-gynecologists can address reproductive health concerns related to environmental exposures without causing unnecessary stress for their patients. Environmental health in obstetricsgynecology medical education. Recognition of environmental hazards among obstetricians-gynecologists has gained momentum with the release of the ACOG Committee on Health Care for Underserved Women and the American Society for Reproductive Medicine (ASRM) Practice Committee joint committee opinion 575.18 In the opinion, ACOG and ASRM urge
Call to Action
ajog.org clinicians to become knowledgeable on potential environmental exposures and to conduct environmental histories of patients during preconception and prenatal visits.18 The joint committee also published a longer, companion piece, which provides guidance to practitioners on specific issues, recommendations for prevention, and additional resources.21 The joint committee opinion demonstrates that reproductive health professionals can be advocates for protecting men, women, and their offspring from exposure to environmental hazards. Further to creating awareness, a formal mechanism to educate obstetricians-gynecologists on environmental health hazards is needed to ensure all trainees are prepared to address patients’ concerns. Over the course of 4 years of medical education, one study found the average number of hours required for environmental health was only 7 hours total.22 Obstetrics-gynecology education has been largely void of environmental health topics aside from nutrition, smoking, and drinking during pregnancy.12 Instruction on taking an environmental history is limited among obstetrics-gynecology medical programs22 with only 1 in 15 obstetricians-gynecologists reporting training specific to taking an environmental history.15 In response to this need, the MidAtlantic Center for Children’s Health and the Environment and the George Washington University Department of Obstetrics and Gynecology convened a meeting of faculty members and residents representing 16 academic medical programs of obstetrics-gynecology in the District of Columbia, Delaware, Maryland, Pennsylvania, Virginia, and West Virginia. The meeting promoted environmental health among the obstetrics and gynecology profession and sought to incorporate environmental health topics into graduate medical education. A work group of faculty members and residents was formed to continue the discussion beyond the meeting on how academic programs of obstetrics-gynecology can
integrate environmental health topics. The work group will identify mechanisms to incorporate environmental health topics, barriers that may exist, and the resources needed to successfully integrate environmental health topics into graduate medical education. Recommendation. Initial avenues identified by the work group for establishing formal training for obstetriciansgynecologists in environmental health include the following topics. Medical school curriculum. Integration of environmental health topics for medical education is necessary at all levels. Methods have been established to assist educational programming development, including integration of environmental health topics into basic science courses and the organ systems approach applied by many curriculums.23 Faculty members at the George Washington University Department of Obstetrics and Gynecology have started creating a medical school and residency curriculum on environmental health specifically for obstetriciansgynecologists. Clinical trainee programs. The University of California, San Francisco, Program on Reproductive Health and the Environment (PRHE) has an established program dedicated to creating awareness of environmental health among reproductive health professionals. The program includes a rotations program for obstetrics-gynecology clinical trainees and maternal-fetal medicine fellows. The PRHE has developed resources for reproductive health professionals, including patient educational materials and environmental health history forms for clinical practice (http://prhe. ucsf.edu/prhe/clinical_resources.html). Obstetrics and gynecology medical programs can use the PRHE as a model for integrating environmental health into fellowships and graduate medical education. Inclusion on resident training and board-certifying exams. Inclusion of environmental health questions on resident
training exams and board-certifying exams would prompt programs to include environmental health topics in their curriculum. The authors suggest that the Council on Residency Education in Obstetrics and Gynecology, the American Board of Obstetrics and Gynecology, and the American Osteopathic Board of Obstetrics and Gynecology consider including environmental health questions on their exams. Faculty training. Leaders in medical education and faculty members could be trained on reproductive environmental health through the Association of Professors of Gynecology and Obstetrics or by establishing environmental health faculty champions programs23 for obstetricians-gynecologists. Continuing education requirements. Requiring continuing education credits in environmental health would ensure that currently practicing obstetriciansgynecologists receive an introduction to environmental health topics. The Agency for Toxic Substances and Disease Registry has developed environmental medicine case studies available to all health professionals required to complete continuing education23 (www.atsdr. cdc.gov/emes/health_professionals/index. html).
Comment By providing obstetricians and gynecologists with the information needed about environmental health hazards, obstetricians and gynecologists can protect their patients, particularly women, at all stages of their lives from environmental hazards. Efforts are needed to support environmental health practice among obstetricians and gynecologists. Including obstetriciansgynecologists in the field of environmental health can assist in identifying new research questions and add perspective to broaden the field of environmental health. In light of the ACOG and ASRM joint committee opinion and the strengthening scientific evidence, it is hoped that the community of obstetrician-gynecology educators will
FEBRUARY 2015 American Journal of Obstetrics & Gynecology
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Call to Action respond with an expanded environmental health education. REFERENCES 1. Woodruff TJ, Zota AR, Schwartz JM. Environmental chemicals in pregnant women in the United States: NHANES 2003-2004. Environ Health Perspect 2011;119:878-85. 2. Newbold RR, Heindel JJ. Developmental exposures and implications for early and latent disease. In: Woodruff TJ, Janssen SJ, Guillette LJ, Guidice LC, eds. Environmental impacts on reproductive health and fertility. New York: Cambridge University Press; 2010:92-102. 3. Debes F, Budtz-Jørgensen E, Weihe P, et al. Impact of prenatal methylmercury exposure on neurobehavioral function at age 14 years. Neurotoxicol Teratol 2006;28:536-47. 4. Grandjean P, Weihe P, Nielsen F, et al. Neurobehavioral deficits at age 7 years associated with prenatal exposure to toxicants from maternal seafood diet. Neurotoxicol Teratol 2012;34:466-72. 5. Grandjean P, Weihe P, Debes F, Choi AL, Budtz-Jørgensen E. Neurotoxicity from prenatal and postnatal exposure to methylmercury. Neurotoxicol Teratol 2014;43:39-44. 6. Stern AH, Smith AE. An assessment of the cord blood: Maternal blood methylmercury ratio: Implications for risk assessment. Environ Health Perspect 2003;111:1465-70. 7. Perera F, Herbstman J. Prenatal environmental exposures, epigenetics, and disease. Reprod Toxicol 2011;31:363-73.
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Abstract for: Medical education for obstetricians and gynecologists should incorporate environmental health Veronica A. Tinney MPH; Jerome A. Paulson MD; Susanne L. Bathgate MD; John W. Larsen MD
Obstetricians-gynecologists can protect the reproductive health of women, men, and their offspring from environmental hazards through preconception and prenatal counseling and encouraging patients to take actions to reduce environmental exposures. Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, education on environmental health in medical education is limited. The MidAtlantic Center for Children’s Health and the Environment and the Department of Obstetrics and Gynecology of George Washington University convened a meeting to begin integration of environmental health topics into medical education for obstetriciansgynecologists. Several avenues were identified to incorporate environmental health topics into medical education including continuing education requirements, inclusion of environmental health questions on board certification examinations and the creation of a curriculum on environmental health specific to obstetrics-gynecology. Key words: environmental exposures, medical education, prevention
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