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May 1999 Meetings of the Education and Practice Workgroups

Executive Summary

In May 1999, EPA and several other federal agencies convened two workgroups of health professionals to identify strategies for raising knowledge and awareness of pesticide issues in the educational and practice settings of primary care providers. A primary care provider is defined as physician, nurse, nurse practitioner, physician assistant, nurse1999 workgroup image midwife, or community health worker specializing in one of the following areas: family medicine, internal medicine, pediatrics, obstetrics/gynecology, emergency medicine, or public health.

Workgroup members came from academic faculty; professional associations for physicians, nurses, and physician assistants; farmworker and community interest groups; federal and state agencies, and pesticide experts. Key themes and findings that emerged from the May 1999 discussion include:

The Education and Practice Workgroups came out of an April 1998 workshop that launched EPA's Pesticides and National Strategies for Health Care Providers initiative. The workgroups used the findings and recommendations of the 1998 workshop to develop a set of strategies and action plans which are described below.

Education Workgroup

Strategy I: Define and integrate "competencies" into the curriculum: Determine what students and faculty should know and do, and how the knowledge and skills should be integrated into the curricula of basic, advanced, and specialty education.

Strategy II: Strengthen and build faculty champions: A $30 million initiative is proposed to fund faculty champions for pesticides in the broader context of environmental health issues in every academic health center in the nation, as well as in other targeted institutions.

Strategy III: Make the case for why medical and nursing schools should include more pesticides and environmental health instruction in their curricula.

Strategy IV: Create incentives for educational institutions to teach environmental health/pesticides: The primary emphasis will be on developing and incorporating questions on pesticides and environmental health on Board exams. The possibility of a White House Initiative to raise the visibility of this issue was also recommended.

Strategy V: Disseminate existing resources and develop new ones for educating both faculty and students in the health professions on environmental health concerns, including pesticide-related health issues.

Practice Workgroup

Strategy I: Define practice behaviors and accompanying content, and integrate content into practice: Define the knowledge and skills related to pesticides that are appropriate for primary care providers. Integrate content into practice settings by educating health providers to be aware of pesticide issues, using a team approach to link providers into networks, and ensuring that health providers can identify and respond to pesticide-related health concerns.

Strategy II: Create incentives for primary care providers to change their practices: Six recommendations were developed (1) fund model programs that work in different practice settings, (2) expand the number of primary care providers taking continuing education credits involving pesticides and environmental health, (3) increase providers' awareness of the value of asking occupational and environmental questions for optimizing Evaluation and Management coding, (4) require knowledge of environmental health issues for recertification, (5) integrate pesticide health effects into workers compensation systems, and (6) promote documentation of occupational and environmental history in medical records.

Strategy III: Promote change in practice settings: By 2010, redesign half of all primary health care practice settings in the United States to incorporate environmental considerations in the following areas: prevention, education, management, and referral.

Strategy IV: Increase the availability and use of tools and methods for primary care providers in clinical and public health settings. These could include teaching modules, websites, train the trainer programs, speaker networks, "10 ABCs," Environmental Health Committees in professional organizations, etc.

A third workgroup on Resources will convene in August 1999. These proceedings will incorporate the results of their deliberations and will serve as a working document for the next year of activity on this initiative, culminating in a National Forum in 2000. EPA encourages all interested organizations to become involved in this initiative as it develops.

Background and Findings

Pesticides and National Strategies for Health Care Providers is an initiative created by the U.S. Environmental Protection Agency (EPA) in collaboration with the Department of Health and Human Services, the Department of Agriculture, and the Department of Labor to identify strategies for educating health care providers on how to recognize, diagnose, and manage pesticide-related health concerns. The National Environmental Education and Training Foundation (NEETF) is working with these agencies in organizing the initiative's events.

A forum of expert advisors was held in April 1998 to launch the initiative. To carry forward the work of this initiative, workgroups were created in three core areas: Formal Education of Health Care Providers, Health Care Provider Practice, and Resources for Health Care Providers. Each workgroup is comprised of 20-25 representatives of key stakeholder organizations and institutions in the field, reflecting the multi-disciplinary nature of the issue of pesticides and health care providers. Several federal representatives also serve on each group.

Workgroup Meetings

The Education and Practice Workgroups met in May 1999. Their deliberations are summarized in this section, and the implementation plans that emerged from the meetings are developed in Part II of this document. The Resources Workgroup will meet in August 1999, and the results of that meeting will be incorporated into a revised version of this document as well.

The Education Workgroup met in Washington, DC on May 3-5; the Practice Workgroup met on May 5-7. A lunchtime session on May 5 was held with both groups, offering the Practice Workgroup a summary of what 1999 workgroup imagethe Education group had achieved in the previous days, and encouraging informal exchanges of information and ideas between the two groups.

Both workgroups discussed competencies and expected outcomes, and devoted some time to brainstorming sessions on overall strategies and plans of action. Small group discussions took up the better part of the second day of each meeting, at which the strategies and action items were fleshed out in more detail. The groups then reviewed the strategies and decided on next steps. Both short-term (1-3 year timeframe) and longer-term actions (3-5 years) were identified. The meetings were moderated by Susan West of the National Environmental Education and Training Foundation (NEETF).

The Education Workgroup was charged with developing a national strategic plan to enable undergraduate and graduate formal education and training institutions to prepare primary care providers to prevent, diagnose, treat, and refer patients exposed to pesticides. The workgroup was expected to set (and/or select already established) competencies for the educational setting, based on Strategy 1 on pages 30-32 of the 1998 Proceedings. The group was also asked to identify strategies on how to achieve those competencies through education, training, and raising student awareness.

The Practice Workgroup was charged with developing a national strategic plan for improving the practice of primary care providers in preventing, diagnosing, treating, and referring patients exposed to pesticides. This group, too, was expected to set (and/or select already established) competencies for the practice setting (based on Strategy 1 on pages 30-33 of the 1998 Proceedings) and to identify strategies on how to achieve those competencies through education, training, and raising awareness.

The Resources Workgroup will focus its attention exclusively on the types of resources that should be developed for primary care providers and how to effectively link providers to the resources. Because of the importance of the issue, both the Education and Practice Workgroups spent some time developing their ideas on resources as well, which will help guide the in-depth consideration by the Resources Workgroup.

Background on the Initiative

The initiative on pesticides and health care providers received its impetus from a number of sources. A primary contributor is EPA's Worker Protection Standard which is designed to reduce pesticide exposure to agricultural workers, mitigate exposures that occur, and inform agricultural employees of the hazards of pesticides. The regulation, implemented in 1995, mandates that millions of farmers, pesticide applicators and farmworkers be educated about the health effects of pesticide exposure and the need to get medical treatment for such effects. This in turn is expected to create additional demand for services from primary care providers.

After the first year of implementation of the Worker Protection Standard, EPA held nine public meetings to evaluate the progress of implementation and hear the experiences of the people most affected by the regulation. One clear message was the need to improve the recognition, diagnosis, and management of pesticide poisonings on the part of all primary members of the health care community.

Although the primary populations affected by pesticides are the 3 to 4.5 million farmworkers in America and the million or more pesticide applicators, pesticides have become ubiquitous in our society. Urban and suburban exposures to pesticides through lawn care products and insecticides in the home and workplace are affecting the population at large. Homeowners annually use 5-10 pounds of pesticide per acre on their lawns and gardens, many times the amount applied by farmers to corn and soybean fields. Primary care providers in urban settings are even less likely to "think pesticides" in taking patient histories or diagnosing illnesses. Therefore, this initiative addresses both agricultural and non-agricultural exposures to pesticides.

Americans look to their primary care providers for guidance on health concerns. Increasingly, such concerns include the effects of environmental and occupational hazards - including pesticides - on their health. While some progress has been made in introducing environmental health issues into the curriculum of medical and nursing schools, most health professionals still do not have adequate knowledge and tools to address patient and community concerns.

Expert Forum

The first project of the Pesticides and National Strategies for Health Care Providers initiative convened an expert forum to develop national strategies to improve the education and awareness of health care providers in dealing with pesticide-related health concerns. The workshop, held on April 23-24, 1998 in Arlington, VA, was sponsored by EPA in collaboration with the Department of Health and Human Services, Department of Agriculture, and Department of Labor. The Association of Teachers of Preventive Medicine and NEETF worked with these federal agencies to organize the event.

The expert forum was conceived of as a deliberative session of representatives of 16 health organizations, open to the public, and with comments and questions from federal agencies and outside observers. The panel included representatives from: American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American Association of Colleges of Nursing, American Association of Poison Control Centers, American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Nurses Association, Council of State1999 workgroup image and Territorial Epidemiologists, Migrant Clinicians Network, National Center for Farmworker Health, National Organization of Nurse Practitioner Faculties, National Pesticide Telecommunications Network, National Rural Health Association, Pennsylvania State University/National Agromedicine Consortium, and Suncoast Community Health Centers.

Concerns About Provider Education and Training

The panel agreed that the primary focus of this initiative should be on primary care providers. The panel found that primary care providers are not sufficiently trained at any stage of their education about pesticide exposure. The panel also recognized that the lack of training is larger than just pesticides and reflects serious deficiency in education on environmental and occupational health. The panel briefly summarized the main concerns in provider knowledge about pesticide exposures:

Expected Outcomes for Primary Care Providers

The panel discussed at length what should be expected of primary care providers. Agreement was reached that all primary care providers should:

Expert Panel's Overarching Strategies

The expert panel generated specific strategies that were consolidated into four general topic areas:

  1. Define and recommend basic environmental health (emphasizing pesticides) competencies for primary care providers.
  2. Develop a set of education and training strategies for students and primary care providers on the subject of pesticide-related health concerns.
  3. Raise the awareness of primary care providers on pesticide issues and risk factors through professional meetings, informational mailing by professional associations, and journal articles.
  4. Centralize information resources for primary care providers and strengthen their linkage to existing resources.

Key Principles and Findings

Members of the Education and Practice Workgroups agreed with the findings and outcomes identified by the expert panel, particularly that primary care providers are not sufficiently trained at any stage of their education about pesticide exposure. One workgroup member noted that even physicians working with farmworkers are often unfamiliar with cholinesterase testing and the fact that it is useful only for certain pesticides (organophosphates and carbamates). Other key principles and findings of the workgroups include:

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