The new curriculum module was incorporated into the Human Dimension (HD), a three-year longitudinal course at the heart of the HMSOM curriculum. Through service-learning experiences and an integrated curriculum, students understand the many Determinants of Health, including the social determinants of health as well as the personal, economic, and environmental determinants. Students are matched to individuals and families from underserved areas, and through longitudinal interactions over the entire core curriculum, they become involved in all aspects of the family’s life to understand drivers of health outcomes, provide education, and navigate community resources. Activities include meetings and calls with individuals and families in their homes and communities as well as participation in multidisciplinary teams in health care, legal, and social services settings.
As part of this effort, the research team created an Environmental Health module delivered via a two-hour interactive large group learning module (lecture) with follow-up activities (a six-week-long student activity highlighting the ways in which the environment and medicine intersect and then a small group discussion session to process that experience). The lecture was titled, “Environmental Health: What Do Physicians Need to Know?” and given by BK. Lecture topics included the health effects of exposures to common toxins, avoiding carcinogens and endocrine disruptors, choosing healthier food and personal care products, the health impacts of climate change, and identifying populations at most risk for environmental health issues. The lecture included two small group discussion periods on questions of how to communicate effectively with patients regarding environmental health and how to begin to make changes in one’s own behaviors. The activity had two components; first, students were asked to download the “Healthy Living” app produced by Environmental Working Group, which provides details on the environmental safety of a wide range of foods and personal care products. Students were asked to explore their diet and personal care choices by identifying 5–10 items and using the app to assess the relative safety of those products from an environmental health perspective. In addition, students were provided with a set of assessment tools to use to understand the potential environmental exposure risk of their HD family. The EH module is delivered midway through the first year of the HD curriculum, and both small group discussions and the community-based work with the HD family is overseen by the HD course faculty who have received faculty development sessions on this topic.
The EH module was given during two subsequent years at the medical school. In year 1, the 15-question Environmental Health in Med School (EHMS) survey was given in January 2019 and the post was given in March 2019. This tool was developed by ESI, GPZ and BK. While there were approximately 60 first-year students invited to take the survey, there were 36 subjects who had data on both the pre and post surveys and were included in the statistical analysis.
For statistical analysis of the EHMS, data were summarized for each question both pre and post with counts and percentages. Responses on the pre survey were compared to those on the post survey using McNemar’s test of agreement. For statistical purposes, results were collapsed as follows, excluding neutrals: True = Definitely true/Somewhat true; False = Definitely false/Somewhat false; Agree = Strongly agree/Agree; Disagree = Strongly disagree/Disagree.
In year 2, students took a newly-created 4-question Environmental Health Survey II (EHS II) before their EH module in November 2019 and again as a post survey in March 2020. This tool was created by BK, who gave the EH lecture in the large group learning module. A total of 84 students took the pre survey, and 79 took the post.
The two surveys were designed to help inform subsequent revisions to the module content to ensure learning objectives were met. These objectives broadly align with the six competency-based environmental health learning objectives from the Institute of Medicine .
The Year 1 EHMS survey was designed to evaluate medical students’ attitudes, awareness and professionalism regarding environmental health. Each of the three constructs that were measured had five corresponding questions in the survey, for a total of 15 questions. A Delphi panel of five experts with backgrounds in curriculum design were asked to rate each question based on three criteria: Is the question appropriate for this survey, is the question clearly written, and is the question in the correct sequence? Each of these had yes/no response options followed by “If no, what are your suggestions for improvement?”
A total of two rounds of the Delphi process were conducted until at least 80% consensus was reached on each question. To control the validity issues associated with the Delphi technique, the survey questions were revised to provide clarity where needed. Based on this first survey, a new survey (EHS II) was created for Year 2 of new, incoming medical students. This brief survey was designed to measure students’ perceptions of preparedness to discuss EH with future patients as opposed to their attitudes, awareness, and professionalism. There were no tests of reliability or validity for this EHSII. The questions were: 1) I feel prepared to advise my patients on strategies for minimizing exposure to pesticides and other environmental toxins in their diet. 2) I feel prepared to advise my patients on strategies for minimizing exposure to environmental toxins in their household and personal care products. 3) I know enough to advocate in my community to try to reduce the health-related impact of environmental toxins on air and water quality. 4) I feel prepared to discuss the specific impacts of climate change on human health. Response options were organized into a 5-point Likert scale ranging from “totally disagree” to “totally agree.” For the EHSII, the Wilcoxon signed-rank test was used to ascertain whether the EH module was effective in promoting medical students’ preparedness to discuss environmental health with their patients.
Data from both surveys was collected non-anonymously using a secure system. To protect participants’ confidentiality, only the HMSOM Institutional Effectiveness and Assessment team had access to identifying information. They provided de-identified data to the research team, including unique identifiers created solely for this project to link the pre and post survey responses. The pre and post surveys fell under the written consent already obtained from the students for LongMED, a database that supports an epidemiologic, longitudinal, outcomes-focused approach to the study of medical education. LongMED contains protected, linked data tied to medical students at the HMSOM.
All students completed the pre and post surveys as part of the curriculum, but the HMSOM sent the research team only the responses for the students who consented to participate in LongMED. Students’ interaction with the instructor and their grade in the HD course were not affected in any way by taking or declining to take the pre and post survey. All first-year medical students (approximately 60 in Year 1 and 85 in Year 2) at the HMSOM, who consented to use LongMED and attended the HD Module, were invited to participate. The final study protocol, survey and data collection tool were approved by the Institutional Review Board (IRB) at Hackensack University Medical Center, Hackensack, New Jersey, USA.
The specific content of the lecture including PowerPoint slides as well as detailed descriptions of the other elements in the EH module are available as Additional files 1 and 2 to this paper.