- Email: [email protected]
Pediatric Environmental Health Competencies for Specialists
Pediatric Environmental Health Competencies for Specialists Ruth A. Etzel, MD, PhD; Ellen F. Crain, MD, PhD; Benjamin A. Gitterman, MD; Charles Oberg, MD, MPH; Peter Scheidt, MD, MPH; Philip J. Landrigan, MD, MSc Background.—Because environmental health problems are complex and require specialty training, the Ambulatory Pediatric Association initiated a 3-year postgraduate fellowship in Pediatric Environmental Health. Objective.—To develop competencies for the specialty of Pediatric Environmental Health and appropriate measures (performance indicators) for the achievement of these competencies. Methods.—The President of the Ambulatory Pediatric Association appointed a 6-member Fellowship Oversight Committee to guide the development of the Fellowship Program and to draft competencies for fellows in Pediatric Environmental Health. The Committee developed a list of proposed competencies for graduates of Pediatric Environmental Health fellowships. These were skills identified as very important for a specialist to have for minimal competency in the practice of pediatric environmental health. Results.—Twenty-seven Pediatric Environmental Health competencies are proposed. The competencies are presented from 3 separate perspectives: academic, individual patient care, and community advocacy. Each competency has a list of suggested performance indicators. Conclusion.—These competencies are intended to assist in structuring the training experience, achieving consensus with respect to expectations of fellows and faculty, providing opportunities for fellows to assess their own needs or gaps in training, and identifying the expertise of fellowship graduates to potential employers. KEY WORDS:
competency; competency-based education; pediatric environmental health
Ambulatory Pediatrics 2003;3:60 63
C
hildren in America and in other industrially developed nations inhabit a world that is fundamentally different from that of past generations. Many infectious diseases have been controlled: smallpox is eradicated, polio is nearly gone, measles is under control, diphtheria and tetanus are rarities, and cholera has virtually disappeared. Infant mortality has been greatly reduced. The expected life span of a baby born today is more than 2 decades longer than that of an infant born at the beginning of the 20th century.1–3 With the decline of many acute infectious diseases of childhood, a number of chronic, disabling diseases (such as asthma and neurodevelopmental problems) are increasing4,5; this situation has been termed the ‘‘new pediatric morbidity.’’ Increasingly, investigators are demonstrating links between certain chronic illnesses and exposures to contaminants in the environment.6–10 In 1999, the American Academy of Pediatrics published the Handbook of Pediatric Environmental Health to summarize the grow-
ing body of evidence linking environmental hazards and children’s health.11 On the other hand, there is a growing body of literature suggesting that interacting with the natural environment gives children a better appreciation of reality,12 arouses their natural curiosity13 and leads to increased creative activities.14 Especially relevant may be the observation that conflicts between children are reduced in frequency in natural play areas.15 Pediatricians need to know more about positive links between environment and health. They also need to learn how to recognize toxic exposures and to diagnose and treat illnesses linked to environmental hazards.16 The typical medical school curriculum devotes little time to environmental health. A national survey conducted by investigators at the University of Massachusetts Medical School17 found that the average curriculum time allocated to topics in environmental and occupational health in the 4 years of medical school was only 6 hours. Similarly, of 127 medical schools responding to a survey from the Association of American Medical Colleges, only 2 reported having a required course in environmental or occupational health.18 A survey of academic deans of American medical schools found that over two thirds of the deans indicated that there was only ‘‘minimal’’ emphasis on environmental health at their institutions.19 Pediatric residency training programs provide only minimal educational opportunities in pediatric environmental health (PEH).20 Typically, residency programs cover only a few topics in this area, commonly a lecture on diagnosis and management of lead poisoning in children and one on the environmental triggers of asthma. One reason that
From the George Washington University School of Public Health and Health Services (Dr Etzel), Washington, DC; the Department of Pediatrics (Emergency Medicine)(Dr Crain), Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY; the Children’s National Medical Center (Dr Gitterman), Washington, DC; the Hennepin County Medical Center (Dr Oberg), Minneapolis, Minn; the National Institute of Child Health and Human Development (Dr Scheidt), National Institutes of Health, Bethesda, Md; and the Mount Sinai School of Medicine (Dr Landrigan), New York, NY. Address correspondence to Ruth A. Etzel, MD, PhD, 4320 Diplomacy Drive, Anchorage, AK 99508 (e-mail: retzel@earthlink. net). Received for publication May 24, 2001; accepted July 15, 2002. AMBULATORY PEDIATRICS Copyright q 2003 by Ambulatory Pediatric Association
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Volume 3, Number 1 January–February 2003
AMBULATORY PEDIATRICS
so few educational opportunities exist in most residency programs is that few pediatric departments have staff with expertise in PEH. Recognizing this growing area of knowledge and the need to develop pediatric faculty members, the Ambulatory Pediatric Association (APA) in 2001 established a new National Fellowship Program in Pediatric Environmental Health. This cross-disciplinary fellowship program will provide 3 years of specialized postresidency training in PEH for selected fellows at 3 competitively selected academic training sites (Children’s Hospital of Boston, Children’s National Medical Center in Washington, DC, and Mount Sinai Medical Center in New York City). The first fellows began their training in July 2002. There is an increasing interest in the incorporation of competency training in graduate medical education.21,22 A competency is defined as ‘‘a cluster of related knowledge, skills, and attitudes that affects a major part of one’s job (a role or responsibility), that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development.’’23 The identification of competencies is viewed as a vehicle for demonstrating educational outcomes in residency and fellowship training programs. METHODS The President of the APA appointed a 6-member Fellowship Oversight Committee to guide the development of the new fellowship program. Our tasks included proposing a definition of the specialty and developing competencies for specialists in PEH and appropriate measures (performance indicators) for the achievement of these competencies. The competencies were developed by asking pediatricians who practiced PEH (15 current and former members of the American Academy of Pediatrics Committee on Environmental Health, whose names are listed in the acknowledgments) to identify those skills a specialist would need to be minimally competent to perform his/her job. Suggestions made by small group leaders at the Environmental Protection Agency–sponsored Pediatric Environmental Health Workshop for Chief Residents at the Pediatric Academic Societies Meeting in Baltimore, Md, on April 29, 2001, were also incorporated. The proposed list of competencies was then ranked by members of the Committee on Environmental Health. Using a scale of 1 to 5, with 5 indicating ‘‘very important,’’ the competencies that were rated as ‘‘important’’ and ‘‘very important’’ were included in the final list of competencies. RESULTS The following definition of PEH specialists was proposed: PEH specialists are pediatricians with special expertise in the etiology, prevention, evaluation, and management of conditions that are experienced by children (as compared to adults) who are exposed to hazardous agents in the environment. Also, they have expertise in
Pediatric Environmental Health Compentencies
61
evaluating children whose parents and/or communities are concerned about possible environmental exposures. With a focus on prevention, the PEH specialist intervenes to reduce or eliminate environmental risks and to promote the health of children. When illness does occur, the PEH specialist determines if the symptoms appear to be linked to environmental exposure and then diagnoses and treats the illness expeditiously and effectively. Because many, if not most, of the health consequences to children related to the environment are the result of agricultural, housing, and land use, or to industrial activities considerably removed from the traditional scope of medicine, PEH specialists understand the potential implications of decisions in these arenas on children’s health, and they use advocacy skills to address these activities to protect and promote children’s health. Through training and experience, the PEH specialist develops specific competencies to achieve this mission. The list below is a set of 27 proposed competencies for PEH specialists. The competencies are presented from 3 perspectives: academic, individual patient care, and community advocacy. These competencies will assist in the following: 1) structuring the training experience, 2) achieving consensus with respect to the expectations of fellows and faculty, 3) providing opportunities for fellows to assess their own needs or gaps in training, and (4) identifying the expertise of fellowship graduates to potential employers and fellowship funding sources. Some of the competencies listed are general competencies, likely to be expected of physicians in most fellowship programs. These are indicated by the initials ‘‘G’’ for ‘‘general competency.’’ Other competencies are specific to environmental health fellowships, and these are marked ‘‘EH’’ for ‘‘environmental health.’’ Upon completion of a 3-year fellowship in PEH, each fellow will demonstrate the following competencies: Academic Perspective 1) Write a grant application. (G) 2) Submit a study proposal to an Institutional Review Board. (G) 3) Use the major national data sources to access information about exposures and health outcomes. (EH) 4) Collect primary data, analyze the results, and summarize the findings. (G) 5) Publish a study in a peer-reviewed journal. (G) 6) Appreciate the policy implications and formulate recommendations based on clinical and epidemiologic research findings. (G) 7) Present results of a study at a professional meeting. (G) 8) Develop curricula to teach residents and medical students the fundamentals of pediatric environmental health. (EH) 9) Understand the impact of the natural environment on children’s development and behavior and translate that understanding into practice, teaching, and research. (G) Individual Patient Care Perspective 1) Take an environmental history from a patient/parent. (EH)
62
Etzel et al.
2) Evaluate pediatric conditions linked to the environment and understand pediatric exposures that may lead to disorders in childhood, adolescence, and/or adulthood. (EH) 3) Utilize a specialized environmental health laboratory and interpret results appropriately. (EH) 4) Report appropriate health conditions to the state or local Public Health Department. (G) 5) Develop a plan to reduce a patient’s or a child’s exposure to environmental contaminant(s). (EH) 6) Evaluate the effectiveness of therapies and methods of reducing environmental exposures. (EH) 7) Identify and coordinate available community resources to improve a patient’s well-being. (G) 8) Respond to questions about acute exposures from parents and health care providers who call a Poison Control Center. (EH) 9) Write a case report about an individual patient and critically review the literature on that patient’s environmental health problem. (EH) Community Advocacy Perspective 1) Assess a health problem in a community. (G) 2) Assess an environmental exposure in a community. (EH) 3) Communicate about environmental risks to community members, school board, political groups, and other stakeholders. (EH) 4) Develop and implement a community-based intervention. (G) 5) Evaluate the effectiveness of a community intervention. (G) 6) Work effectively as a member of a multidisciplinary team. (G) 7) Develop media literacy in order to use media education as an advocacy tool in promoting environmental health. (EH) 8) Interpret legal and regulatory authority as well as nonregulatory approaches as they relate to children’s health and the environment. (EH) 9) Prepare and present testimony before local, state, and national legislators. (EH) CONCLUSION These competencies are designed to help fellowship directors identify gaps in the learning opportunities their programs provide, to ensure balance in their program offerings, and to structure new experiences. Giving the competencies to fellows as they begin their training will help them focus on what they need to achieve during their training. The competencies should also help potential employers identify what they can expect of a specialist with PEH fellowship training. We expect that these competencies will continue to be refined as the specialty matures. Regular and timely feedback to fellows about their progress in achieving the competencies is essential. A selected list of performance indicators is available
AMBULATORY PEDIATRICS
from the APA Office and on the APA Website. These are categories of evidence that can be used as a basis for judging the fellow’s achievement of the competency. These performance indicators can be used to distinguish competent from incompetent performance. It is important to note that the performance indicators listed are meant as examples; it is expected that PEH faculty will develop many additional performance indicators. ACKNOWLEDGMENTS We thank the chair and members of the American Academy of Pediatrics Committee on Environmental Health, who generously provided insightful review and critique of the proposed competencies during their April 2001 and April 2002 meetings. They are Drs Sophie J. Balk, Katherine M. Shea, Christine L. Johnson, Robert W. Miller, Mark D. Miller, Martha Linet, William B. Weil, Jr, David W. Reynolds, Walter Rogan, Lynn R. Goldman, Robert W. Amler, James R. Roberts, Janice J. Kim, Peter R. Simon, and Michael W. Shannon. We appreciate the additional contributions of the small group leaders at the Environmental Protection Agency–sponsored Pediatric Environmental Health Workshop for Chief Residents at the Pediatric Academic Societies Meeting in Baltimore, Md, on April 29, 2001. The views expressed in this article are strictly those of the authors. No official endorsement by the US Department of Health and Human Services or any of its components is intended, nor should any be inferred.
References 1. DiLiberti JH, Jackson CR. Long-term trends in childhood infectious disease mortality rates. Amer J Public Health. 1999;89: 1883–1889. 2. Haggerty R, Roghmann J, Pless IB. Child Health and the Community. New York, NY: John Wiley and Sons, 1975. 3. CDC. Achievements in public health, 1900:1999: Healthier mothers and babies. MMWR. 1999;48:849–858. 4. DeVesa SS, Blot WJ, Stone BJ et al. Recent cancer trends in the United States. JNCI. 1995;87:175–182. 5. CDC. Asthma—United States, 1982-1992. MMWR. 1995;43: 952–955. 6. Jacobson JL, Jacobson SW. Intellectual impairment in children exposed to polychlorinated biphenyls in utero. N Engl J Med. 1996;335:783. 7. Pocock S, Smith M, Baghurst P. Environmental lead and children’s intelligence: a systematic review of the epidemiologic evidence. Br Med J 1994;309:1189. 8. Davidson PW, Myers GJ, Cox C et al. Effects of prenatal and postnatal methylmercury exposure from fish consumption on neurodevelopment. JAMA. 1998;280:701. 9. Kasatkinan EP, Shilin DE, Rosenbloom AL et al. Effects of low level radiation from Chernobyl accident in a population with iodine deficiency. Eur J Pediatr. 1997;156:916. 10. McConnell R, Berhane K, Gilliland F et al. Asthma in exercising children exposed to ozone: a cohort study. Lancet. 2002; 359:386–391. 11. American Academy of Pediatrics. Handbook of Pediatric Environmental Health. (Eds. Etzel RA, Balk SJ.). Elk Grove Village, IL: American Academy of Pediatrics, 1999. 12. Dewey J. Dewey on Education. New York, NY: Teachers College Press, 1959, p. 37. 13. Gutek EL. Education in the United States. Needham Heights, MA: Allyn and Bacon, 1991, p. 72. 14. Crain W. How nature helps children develop. Montessori Life Spring 1997, pp. 41-43. 15. Moore RC. The power of nature: orientation of boys and girls toward biotic and abiotic play settings on a reconstructed schoolyard. Children’s Environmental Quarterly. 1987;4:11–18. 16. Crain EF. Environmental threats fo children’s health: a challenge for pediatrics: 2000 Ambulatory Pediatric Association (APA)
AMBULATORY PEDIATRICS
17. 18. 19.
20.
presidential address. Pediatrics (J Ambul Pediatr Assn). 2000; 106(4 Suppl):871–875. Levy BS. The teaching of occupational health in United States medical schools. Amer J Public Health. 1985;41:79–80. Association of American Medical Colleges. 1989-1990 AAMC Curriculum Directory. Washington, DC: AAMC 1989. Graber DR, Musham C, Bellack JP, Holmes D. Environmental health in medical school curricula: views of academic deans. J Occup Environmental Medicine 1995;37:807–811. Ferguson SL, Lieu TA. Blood lead testing by pediatricians:
Pediatric Environmental Health Compentencies
63
practice, attitudes, and demographics. Amer J Public Health. 1997;87:1349–1351. 21. Lane DS Ross V, Chen DW, O’Niell C. Core competencies for preventive medicine residents. Version 2.0. Am J Prev Med. 1999;16:367–372. 22. Association of Teachers in Materianl and Child Health. Maternal and Child Health Competencies. February 2001. Available at www.atmch.org/mchcomps.pdf. 23. Parry SR. The Quest for Competencies. Training. July 1996, p. 48-56.
competency; competency-based education; pediatric environmental health
Ambulatory Pediatrics 2003;3:60 63
C
hildren in America and in other industrially developed nations inhabit a world that is fundamentally different from that of past generations. Many infectious diseases have been controlled: smallpox is eradicated, polio is nearly gone, measles is under control, diphtheria and tetanus are rarities, and cholera has virtually disappeared. Infant mortality has been greatly reduced. The expected life span of a baby born today is more than 2 decades longer than that of an infant born at the beginning of the 20th century.1–3 With the decline of many acute infectious diseases of childhood, a number of chronic, disabling diseases (such as asthma and neurodevelopmental problems) are increasing4,5; this situation has been termed the ‘‘new pediatric morbidity.’’ Increasingly, investigators are demonstrating links between certain chronic illnesses and exposures to contaminants in the environment.6–10 In 1999, the American Academy of Pediatrics published the Handbook of Pediatric Environmental Health to summarize the grow-
ing body of evidence linking environmental hazards and children’s health.11 On the other hand, there is a growing body of literature suggesting that interacting with the natural environment gives children a better appreciation of reality,12 arouses their natural curiosity13 and leads to increased creative activities.14 Especially relevant may be the observation that conflicts between children are reduced in frequency in natural play areas.15 Pediatricians need to know more about positive links between environment and health. They also need to learn how to recognize toxic exposures and to diagnose and treat illnesses linked to environmental hazards.16 The typical medical school curriculum devotes little time to environmental health. A national survey conducted by investigators at the University of Massachusetts Medical School17 found that the average curriculum time allocated to topics in environmental and occupational health in the 4 years of medical school was only 6 hours. Similarly, of 127 medical schools responding to a survey from the Association of American Medical Colleges, only 2 reported having a required course in environmental or occupational health.18 A survey of academic deans of American medical schools found that over two thirds of the deans indicated that there was only ‘‘minimal’’ emphasis on environmental health at their institutions.19 Pediatric residency training programs provide only minimal educational opportunities in pediatric environmental health (PEH).20 Typically, residency programs cover only a few topics in this area, commonly a lecture on diagnosis and management of lead poisoning in children and one on the environmental triggers of asthma. One reason that
From the George Washington University School of Public Health and Health Services (Dr Etzel), Washington, DC; the Department of Pediatrics (Emergency Medicine)(Dr Crain), Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY; the Children’s National Medical Center (Dr Gitterman), Washington, DC; the Hennepin County Medical Center (Dr Oberg), Minneapolis, Minn; the National Institute of Child Health and Human Development (Dr Scheidt), National Institutes of Health, Bethesda, Md; and the Mount Sinai School of Medicine (Dr Landrigan), New York, NY. Address correspondence to Ruth A. Etzel, MD, PhD, 4320 Diplomacy Drive, Anchorage, AK 99508 (e-mail: retzel@earthlink. net). Received for publication May 24, 2001; accepted July 15, 2002. AMBULATORY PEDIATRICS Copyright q 2003 by Ambulatory Pediatric Association
60
Volume 3, Number 1 January–February 2003
AMBULATORY PEDIATRICS
so few educational opportunities exist in most residency programs is that few pediatric departments have staff with expertise in PEH. Recognizing this growing area of knowledge and the need to develop pediatric faculty members, the Ambulatory Pediatric Association (APA) in 2001 established a new National Fellowship Program in Pediatric Environmental Health. This cross-disciplinary fellowship program will provide 3 years of specialized postresidency training in PEH for selected fellows at 3 competitively selected academic training sites (Children’s Hospital of Boston, Children’s National Medical Center in Washington, DC, and Mount Sinai Medical Center in New York City). The first fellows began their training in July 2002. There is an increasing interest in the incorporation of competency training in graduate medical education.21,22 A competency is defined as ‘‘a cluster of related knowledge, skills, and attitudes that affects a major part of one’s job (a role or responsibility), that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development.’’23 The identification of competencies is viewed as a vehicle for demonstrating educational outcomes in residency and fellowship training programs. METHODS The President of the APA appointed a 6-member Fellowship Oversight Committee to guide the development of the new fellowship program. Our tasks included proposing a definition of the specialty and developing competencies for specialists in PEH and appropriate measures (performance indicators) for the achievement of these competencies. The competencies were developed by asking pediatricians who practiced PEH (15 current and former members of the American Academy of Pediatrics Committee on Environmental Health, whose names are listed in the acknowledgments) to identify those skills a specialist would need to be minimally competent to perform his/her job. Suggestions made by small group leaders at the Environmental Protection Agency–sponsored Pediatric Environmental Health Workshop for Chief Residents at the Pediatric Academic Societies Meeting in Baltimore, Md, on April 29, 2001, were also incorporated. The proposed list of competencies was then ranked by members of the Committee on Environmental Health. Using a scale of 1 to 5, with 5 indicating ‘‘very important,’’ the competencies that were rated as ‘‘important’’ and ‘‘very important’’ were included in the final list of competencies. RESULTS The following definition of PEH specialists was proposed: PEH specialists are pediatricians with special expertise in the etiology, prevention, evaluation, and management of conditions that are experienced by children (as compared to adults) who are exposed to hazardous agents in the environment. Also, they have expertise in
Pediatric Environmental Health Compentencies
61
evaluating children whose parents and/or communities are concerned about possible environmental exposures. With a focus on prevention, the PEH specialist intervenes to reduce or eliminate environmental risks and to promote the health of children. When illness does occur, the PEH specialist determines if the symptoms appear to be linked to environmental exposure and then diagnoses and treats the illness expeditiously and effectively. Because many, if not most, of the health consequences to children related to the environment are the result of agricultural, housing, and land use, or to industrial activities considerably removed from the traditional scope of medicine, PEH specialists understand the potential implications of decisions in these arenas on children’s health, and they use advocacy skills to address these activities to protect and promote children’s health. Through training and experience, the PEH specialist develops specific competencies to achieve this mission. The list below is a set of 27 proposed competencies for PEH specialists. The competencies are presented from 3 perspectives: academic, individual patient care, and community advocacy. These competencies will assist in the following: 1) structuring the training experience, 2) achieving consensus with respect to the expectations of fellows and faculty, 3) providing opportunities for fellows to assess their own needs or gaps in training, and (4) identifying the expertise of fellowship graduates to potential employers and fellowship funding sources. Some of the competencies listed are general competencies, likely to be expected of physicians in most fellowship programs. These are indicated by the initials ‘‘G’’ for ‘‘general competency.’’ Other competencies are specific to environmental health fellowships, and these are marked ‘‘EH’’ for ‘‘environmental health.’’ Upon completion of a 3-year fellowship in PEH, each fellow will demonstrate the following competencies: Academic Perspective 1) Write a grant application. (G) 2) Submit a study proposal to an Institutional Review Board. (G) 3) Use the major national data sources to access information about exposures and health outcomes. (EH) 4) Collect primary data, analyze the results, and summarize the findings. (G) 5) Publish a study in a peer-reviewed journal. (G) 6) Appreciate the policy implications and formulate recommendations based on clinical and epidemiologic research findings. (G) 7) Present results of a study at a professional meeting. (G) 8) Develop curricula to teach residents and medical students the fundamentals of pediatric environmental health. (EH) 9) Understand the impact of the natural environment on children’s development and behavior and translate that understanding into practice, teaching, and research. (G) Individual Patient Care Perspective 1) Take an environmental history from a patient/parent. (EH)
62
Etzel et al.
2) Evaluate pediatric conditions linked to the environment and understand pediatric exposures that may lead to disorders in childhood, adolescence, and/or adulthood. (EH) 3) Utilize a specialized environmental health laboratory and interpret results appropriately. (EH) 4) Report appropriate health conditions to the state or local Public Health Department. (G) 5) Develop a plan to reduce a patient’s or a child’s exposure to environmental contaminant(s). (EH) 6) Evaluate the effectiveness of therapies and methods of reducing environmental exposures. (EH) 7) Identify and coordinate available community resources to improve a patient’s well-being. (G) 8) Respond to questions about acute exposures from parents and health care providers who call a Poison Control Center. (EH) 9) Write a case report about an individual patient and critically review the literature on that patient’s environmental health problem. (EH) Community Advocacy Perspective 1) Assess a health problem in a community. (G) 2) Assess an environmental exposure in a community. (EH) 3) Communicate about environmental risks to community members, school board, political groups, and other stakeholders. (EH) 4) Develop and implement a community-based intervention. (G) 5) Evaluate the effectiveness of a community intervention. (G) 6) Work effectively as a member of a multidisciplinary team. (G) 7) Develop media literacy in order to use media education as an advocacy tool in promoting environmental health. (EH) 8) Interpret legal and regulatory authority as well as nonregulatory approaches as they relate to children’s health and the environment. (EH) 9) Prepare and present testimony before local, state, and national legislators. (EH) CONCLUSION These competencies are designed to help fellowship directors identify gaps in the learning opportunities their programs provide, to ensure balance in their program offerings, and to structure new experiences. Giving the competencies to fellows as they begin their training will help them focus on what they need to achieve during their training. The competencies should also help potential employers identify what they can expect of a specialist with PEH fellowship training. We expect that these competencies will continue to be refined as the specialty matures. Regular and timely feedback to fellows about their progress in achieving the competencies is essential. A selected list of performance indicators is available
AMBULATORY PEDIATRICS
from the APA Office and on the APA Website. These are categories of evidence that can be used as a basis for judging the fellow’s achievement of the competency. These performance indicators can be used to distinguish competent from incompetent performance. It is important to note that the performance indicators listed are meant as examples; it is expected that PEH faculty will develop many additional performance indicators. ACKNOWLEDGMENTS We thank the chair and members of the American Academy of Pediatrics Committee on Environmental Health, who generously provided insightful review and critique of the proposed competencies during their April 2001 and April 2002 meetings. They are Drs Sophie J. Balk, Katherine M. Shea, Christine L. Johnson, Robert W. Miller, Mark D. Miller, Martha Linet, William B. Weil, Jr, David W. Reynolds, Walter Rogan, Lynn R. Goldman, Robert W. Amler, James R. Roberts, Janice J. Kim, Peter R. Simon, and Michael W. Shannon. We appreciate the additional contributions of the small group leaders at the Environmental Protection Agency–sponsored Pediatric Environmental Health Workshop for Chief Residents at the Pediatric Academic Societies Meeting in Baltimore, Md, on April 29, 2001. The views expressed in this article are strictly those of the authors. No official endorsement by the US Department of Health and Human Services or any of its components is intended, nor should any be inferred.
References 1. DiLiberti JH, Jackson CR. Long-term trends in childhood infectious disease mortality rates. Amer J Public Health. 1999;89: 1883–1889. 2. Haggerty R, Roghmann J, Pless IB. Child Health and the Community. New York, NY: John Wiley and Sons, 1975. 3. CDC. Achievements in public health, 1900:1999: Healthier mothers and babies. MMWR. 1999;48:849–858. 4. DeVesa SS, Blot WJ, Stone BJ et al. Recent cancer trends in the United States. JNCI. 1995;87:175–182. 5. CDC. Asthma—United States, 1982-1992. MMWR. 1995;43: 952–955. 6. Jacobson JL, Jacobson SW. Intellectual impairment in children exposed to polychlorinated biphenyls in utero. N Engl J Med. 1996;335:783. 7. Pocock S, Smith M, Baghurst P. Environmental lead and children’s intelligence: a systematic review of the epidemiologic evidence. Br Med J 1994;309:1189. 8. Davidson PW, Myers GJ, Cox C et al. Effects of prenatal and postnatal methylmercury exposure from fish consumption on neurodevelopment. JAMA. 1998;280:701. 9. Kasatkinan EP, Shilin DE, Rosenbloom AL et al. Effects of low level radiation from Chernobyl accident in a population with iodine deficiency. Eur J Pediatr. 1997;156:916. 10. McConnell R, Berhane K, Gilliland F et al. Asthma in exercising children exposed to ozone: a cohort study. Lancet. 2002; 359:386–391. 11. American Academy of Pediatrics. Handbook of Pediatric Environmental Health. (Eds. Etzel RA, Balk SJ.). Elk Grove Village, IL: American Academy of Pediatrics, 1999. 12. Dewey J. Dewey on Education. New York, NY: Teachers College Press, 1959, p. 37. 13. Gutek EL. Education in the United States. Needham Heights, MA: Allyn and Bacon, 1991, p. 72. 14. Crain W. How nature helps children develop. Montessori Life Spring 1997, pp. 41-43. 15. Moore RC. The power of nature: orientation of boys and girls toward biotic and abiotic play settings on a reconstructed schoolyard. Children’s Environmental Quarterly. 1987;4:11–18. 16. Crain EF. Environmental threats fo children’s health: a challenge for pediatrics: 2000 Ambulatory Pediatric Association (APA)
AMBULATORY PEDIATRICS
17. 18. 19.
20.
presidential address. Pediatrics (J Ambul Pediatr Assn). 2000; 106(4 Suppl):871–875. Levy BS. The teaching of occupational health in United States medical schools. Amer J Public Health. 1985;41:79–80. Association of American Medical Colleges. 1989-1990 AAMC Curriculum Directory. Washington, DC: AAMC 1989. Graber DR, Musham C, Bellack JP, Holmes D. Environmental health in medical school curricula: views of academic deans. J Occup Environmental Medicine 1995;37:807–811. Ferguson SL, Lieu TA. Blood lead testing by pediatricians:
Pediatric Environmental Health Compentencies
63
practice, attitudes, and demographics. Amer J Public Health. 1997;87:1349–1351. 21. Lane DS Ross V, Chen DW, O’Niell C. Core competencies for preventive medicine residents. Version 2.0. Am J Prev Med. 1999;16:367–372. 22. Association of Teachers in Materianl and Child Health. Maternal and Child Health Competencies. February 2001. Available at www.atmch.org/mchcomps.pdf. 23. Parry SR. The Quest for Competencies. Training. July 1996, p. 48-56.