Pesticide Effects: Integration Into Health Care Provider Curriculum

1. Pesticide Effects: Integration Into Health Care Provider Curriculum P.I. Matthew Keifer Dep. Environmental and Occupational Health Sciences, Occupational Medicine Program, Schools of Medicine and Public Health U.W. Co-P.I. Helen Murphy Pacific Northwest Agricultural Health Center, UW

2. Other Partners • Ruth Balweg, Medex Northwest • Patricia Butterfield, Nursing UW • Mary Ann Draye, FNP program UW • Erec Leber, Sciences Heritage University • Sandra Wells Nursing, Heritage University • Linda Petersen, Nursing, Seattle Pacific University

3. Other Partners • Susan Marshall, School of Medicine, UW • Daniel Sudakin, National Pesticide Medical Monitoring Program OSU • Joanne Elmore General Internal Med UW • Jordan Firestone, Neurology and Occupational Med UW • Dennis Shusterman, Family and Occupational Med UW • Catherine Karr, Pediatrics UW

4. Other Programs • Medical and Nursing Practice Initiative • Migrant Clinicians Network • Similar to our own but aimed at the practicing provider • Interaction will be assured due to overlapping personnel • Initial Meeting will be Jan 27th. Portland

5. Fly swatter developed 1203 BC How Did We Get Here? Mueller discovers DDT 1938 AMA Recommends Enhance Pesticide Capabilities 1994 IOM Reports 1995 and 1999 Schenk et al Med Training 1996 • 1994 AMA recommends enhancing response to pesticide risks. • IOM in 88, 91, 93, 95,99 Deficits in Environmental and Occupational Health Training • Nat Strategies for Health Care Provider Initiative 1998 • Implementation Plan: National Stragegies • EPA issued double RFA March- 2005 • Notice of AWARD Sept 2005 • Official Notice Lost in Mail: Oct 2005 • OfficialNotice found: November 2005 • First Team Meeting: Today National Strategies 1998 Recognition & Management of Pesticide Poisonings 1999 Implementation Plan 2002 EPA RFA 2005

6. Basic Tenets of the Initiative • Lack of Training in Env-Occ Health topics • Pesticide Training will serve as a Model for other Occ and Env Health Information • Points of Insertion Integrate-ability of Pesticide Information • Multiple Curricular Models • Tailored Modules • Easy adoption • Faculty Champions • The key to success

7. Our Proposal • Specific Aims: • Engage Key Faculty from the Northwest • Develop Modules: • Primary & Secondary • Identify Integration Points • Different Curricular Models

8. Our Proposal • Specific Aims: cont. • Evaluate differing strategies • Evaluate effect of integration: knowledge • Develop dissemination plan • Enlist champions in promotion • Enlist students and emerging champions

9. Strengths of Our ProposalStrength of our Team • Deans, Chairs, Directors, and Key Faculty in various disciplines • Leaders, locally and nationally • Importance of the Topic • Importance to Industry and recent legal changes in the state • Recent Changes in Washington State: Cholinesterase Monitoring Rule • Diversity of our partner programs

10. Strengths of our Proposal • Strength of UW in Pesticide Health Issues • PNASH Center • UW Pesticide Focus • Environmental Health Laboratory • Stacey Holland graphic artist • We will be evaluating throughout • Did they learn? • Was the material user friendly? • Did the Models Fit?

11. DOMAINS

12. Domains Where Pesticides Might Reach • Basic Science • Chemistry, Biochemistry, Genetics, Physiology, Immunology • Clinical Science • History, physical exam, Laboratory medicine, case management, Pathology, Toxicology • Public Health • Surveillance, Industrial Hygiene, Case reporting, Epidemiology, Long term studies, Risk assessment, Exposure evaluation, • Social Sciences • Environmental, Economic, Worker rights, Public Policy • Specialties: Occupational med, Family med, Peds, Neurology, Dermatology, Clinical Toxicology • Other: • Scientific uncertainty and Precautionary Principal

13. DRAFT of ChE inhibition ppt animation - currently unavailable - UNDER CONSTRUCTION

14. PAUSE

15. MEDEX Northwest Division of Physician Assistant StudiesPhysician Assistant Training ProgramPesticide Training and MEDEX Curriculum Integration

16. A-Term: MEDEX 451Anatomy & Physiology(6 credits)Students are taught the anatomy and physiology of the following organ systems: endocrine, immune, respiratory, cardiovascular, gastrointestinal, genitourinary, gynecological, integumentary, musculoskeletal and neurologic, with a focus on clinical examples of anatomic and physiologic principles encountered in primary care practice. Course is required for all incoming MEDEX students. Offered via distance education (online) in Spring Quarter with a two-week intensive session on the Seattle campus in July.B-Term: MEDEX 450Basic Science in Clinical Medicine for Physician Assistants(6 credits)This course is an intensive review of, and in some cases introduction to, important basic science topics relevant to clinical medicine at the physician assistant level. The material is necessary to the understanding and integration of information that will be presented throughout the remainder of the MEDEX curriculum. Topics to be covered include cell biology, genetics, immunology and microbiology. Insertion point : Neuro-physiology of cholinergic pesticide poisoning Insertion point : Genotoxicity, gen-environmental interaction and immunotoxicity of pesticides S U M M E R Q U A R T E R

17. MEDEX 452Basic Clinical Pathology (6 credits)Course covers basic pathological and pathophysiological concepts of diseases commonly encountered in primary care practice. Pathophysiology is studied per organ system.MEDEX 453Basic Clinical Skills (5 credits)This course provides the student with mastery of a screening history and physical examination and thoroughness in data-collection skills. Branching examinations of major organ systems, medical record-keeping and verbal presentation skills by the problem-oriented method are taught.MEDEX 457Behavioral Science Skills I (2 credits)Learn process skills and interpersonal skills needed for primary care practice, assessment skills needed for the diagnosis of emotional problems, and management skills used in primary-care practice to deal with these problems. Insertion point : Toxic effects of pesticides on various systems Insertion point : Organ specific effects of pesticides, (eg Lung and Paraquat) F A L L Q U A R T E R Insertion point : Environmental and Occupational Exposure History, Screening and monitoring for pesticide exposure Insertion point : Behavior and Occupational Disease, PTSD from chemicals events. Nueurological effects manifest a depression

18. Insertion point : EH as an emerging issue. Pesticide exposure in schools, from water, from home use, in food, in soil. MEDEX 470PA Role Course I(1 credit) Introduction to the PA role including relationships with other health professions, role transitions and emerging issues in primary care. This course emphasizes learning between classmates about their prior roles in a wide range of urban and rural communities. MEDEX 473Technical Skills I(1 credit) This course introduces clinical skills and procedures through hands-on experiences to physician assistant students. In the first quarter, the student is introduced to heart sounds, electrocardiogram and radiograph interpretation, gynecological and genitourinary physical examination skills and acquires fundamental dictation skills. Insertion point : clinical presentation of pesticide overexposure. F A L L Q U A R T E R continued

19. Insertion point : Include pesticide poisoning in differentials where appropriate. Include management of work related and environmentally related illness. MEDEX 454 Adult Medicine I(7 credits) Course provides a problem-oriented approach to the diagnosis and management of common primary care conditions. Organ system approach covers HEENT, rheumatology, anemia, STD/HIV and cardiovascular, gastrointestinal and hematological systems. MEDEX 456 Maternal & Child Health I(3 credits) This course is designed to acquaint students with principles of prenatal care and primary care pediatrics. The course covers prenatal care, labor & delivery, newborn and well-child exams and a systems-oriented approach to the diagnosis and initial management of common primary care pediatric conditions. Concepts of health maintenance for children and well-child care are covered. Insertion point :Prevention of pesticide exposure in women of CBA and children. How do pesticide overexposures manifest in children. W I N T E R Q U A R T E R

20. Insertion point : Extension of depression and neurobehavioral effects of pesticide overexpsure MEDEX 458 Behavioral Science Skills II(2 credits) Continuation of MEDEX 457. Course provides in-depth coverage of common emotional problems seen in primary care. Topics include crisis intervention, child abuse, death and dying, life planning, behavioral modification and family therapy techniques. MEDEX 460 Principles of Patient Management(3 credits) Teaches a systematic approach to patient management applicable to a primary care setting. The course is devoted to drug therapy and its administration. Organ-system approach generally matches topic sequence of MEDEX 454. MEDEX 468 Emergency Medicine I(2 credits) Provides an approach to the diagnosis and management of common emergency conditions for primary care physician assistants. Topics include multiple trauma, chest trauma, abdominal trauma, shock and cardiac emergencies. Insertion point : Response to intoxicated patient, Avoidance of exposure of self, Drug treatment with atropine, 2-PAM, etc W I N T E R Q U A R T E R continued Insertion point : Presentations of pesticide poisonings. Data collection for claim filing, Reporting obligations. Communicating with the Employer

21. MEDEX 471 PA Role Course II(1 credit) Continuation of MEDEX 470. This quarter emphasizes knowledge, skills and attitudes for dealing with diverse population groups. MEDEX 474 Technical Skills II(1 credit) Continuation of MEDEX 473. The course expands electrocardiogram interpretation and also includes interpretation of abdominal and orthopedic radiographs and additional focused physical examinations. A series of workshops (slit lamp examination, splinting and casting, venipuncture, introduction to microscopy) will expose students to procedures encountered in the primary care setting. Insertion point : Farmers risk perception and approaches to Hispanic farmworkers, Worker compensation issue and the vulnerable worker Insertion point : More on Diagnosis of Pesticide Poisonings W I N T E R Q U A R T E R continued

22. MEDEX 455 Adult Medicine II(7 credits) Continuation of MEDEX 454. Course provides a problem-oriented approach to the diagnosis and initial management of common primary care conditions. Organ system approach covers endocrine, renal, reproductive, dermatologic,respiratory and neurological systems. MEDEX 459 Behavioral Science Skills III(2 credits) Continuation of MEDEX 458 with the inclusion of topics such as human sexuality, alcohol, drugs and problems with aging. MEDEX 461 Principles of Patient Management II(3 credits) Continuation of MEDEX 460. Organ-system approach generally matches topic sequence of MEDEX 455. Insertion point : Include pesticides where appropriate in differentials (e.g.derm, asthma, reproductive, neuro) Insertion point :ETOH and Cocaine on ChE levels and depression S P R I N G Q U A R T E R Insertion point : More on organ specific effects

23. MEDEX 462 Maternal & Child Health II(3 credits) Continuation of MEDEX 456. The course continues a systems-oriented approach to the diagnosis and initial management of common primary care pediatric conditions. Topics covered include common respiratory, cardiac, orthopedic and dermatologic problems; adolescent medicine and also issues of abuse. MEDEX 469 Emergency Medicine II(2 credits) Continuation of MEDEX 468. Provides an approach to the diagnosis and management of common emergency conditions for primary care physician assistants. Topics include poisonings and overdoses, environmental emergencies, thermal injuries, orthopedic emergencies, pediatric emergencies and head trauma. MEDEX 472 PA Role Course III(1 credit) Continuation of MEDEX 471. This quarter emphasizes current issues in the health care delivery system. Topics include managed care, reimbursement, access and related issues. Insertion point : Special risks of pesticide and other toxin exposures to children. Differentials where appropriate (asthma, derm) Insertion point : Recognition – management of pesticide poisoning S P R I N G Q U A R T E R continued Insertion point : Pesticides and Worker Compensation

24. MEDEX 475 Technical Skills III(1 credit) Continuation of MEDEX 474. This quarter includes further electrocardiogram interpretation and adds a series of related respiratory topics, pulmonary function testing, Gram stain, sputum culture and chest radiograph interpretation. A final series of workshops (IV and endotracheal intubation, suturing, orientation to the surgical suite, introduction to ultrasound, computerized tomography, magnetic resonance imaging) complete the technical skills curriculum. Insertion point :Laboratory interpretation and ordering for diagnosis of pesticide poisoning S P R I N G Q U A R T E R continued

25. Insertion point : Case studies of pesticide poisonings MEDEX 463 Clinical Clerkships I(19 credits) MEDEX 465 Clinical Clerkships II(19 credits) Rotating clerkships offer clinical experience in selected institution-based or specialty practice settings, such as inpatient medicine, ambulatory medicine, orthopedics, emergency medicine, psychiatry, occupational health, surgery or geriatrics. Each clerkship includes seminars or self-study in combination with concentrated clinical experience. Specialty rotations are intended for exposure, not mastery. Clinical Clerkships is a two-quarter segment divided into at least six full-time, four-week clinical rotations in a variety of medical specialty areas. Student assignments are based on required rotations. During clerkships, student progress is monitored through evaluations by clinical instructors, frequent telephone calls and site visits as required. Offered Credit/No Credit only. C L I N I C A L Y E A R

26. Insertion point : Occupational Medicine in Family Practice MEDEX 466 Family Practice Clerkship I(19 credits) MEDEX 467 Family Practice Clerkship II(19 credits) Preceptorship is conducted under the supervision of a family practice physician. Preceptorships are located throughout the WWAMI region. Students are trained to deal with common primary care problems and both student and preceptor are educated in the utilization and management of the physician assistant in practice. Students keep records of patient encounters and complete a variety of written assignments in addition to their clinical experience. The preceptorship is generally a two-quarter segment, although it may be extended in certain cases to permit a student to reach required performance levels. The educational objectives of this phase are: 1) to expand the knowledge and skills acquired during the didactic phase with regard to the diagnosis and management of commonly-encountered primary care problems, 2) to become familiar with office procedures and management, 3) to learn to function as an effective primary care team member and 4) to attain other objectives specified by the individual practice. Offered Credit/No Credit only. C L I N I C A L Y E A R continued

27. PAUSE

28. Activities Year 1 • Recruit student team members • Analyze curricula develop integration plan • Identify insertion points • Train key faculty and students on pesticide topics, issues and methods • Develop insertion points and design packaging plan

29. Your Role, Year 1 • Provide and explain curriculum • Identify insertion points • Suggest packaging models for materials • Review level of detail • Help plan evaluation • Of impact, usability, approach to integration • Recruit students • Identify Faculty Champions