Resident GIM

The Boston Experience

Kerri Johannson, MD

About the Author

Kerri Johannson is a third-year internal medicine resident at the University of Calgary. She has a special interest in the field of environmental medicine.

Boston was amazing in the spring. The air carried the aroma of Fenway franks with Red Sox fans still delirious from last season’s championship series. Marathoners flooded running paths along the Charles River, flowers blossomed on Newbury, and I was lucky enough to be in the thick of it all, doing an elective in occupational and environmental medicine at the Harvard School of Public Health.

I have always been interested in environmental medicine, and whenever I have mentioned this to people, they have invariably asked, “What is environmental medicine?” Not entirely clear, I set off to find out. My elective was a multifaceted ambulatory experience, with the Cambridge Hospital having a permanent office devoted to occupational/environmental medicine (OEM). Many of their clients are manufacturing and industrial companies with anywhere from a dozen to hundreds of workers. If an employee were to be injured at work, they would be initially assessed in the local emergency department and then referred to our clinic. Most common were MSK injuries, but an occasional patient presented with symptoms of acute chemical exposure or metal fume fever. It was our job to assess the relationships of potential exposures/injuries to health outcomes and to make medical recommendations for returning to work and how work might be modified for improved safety.

Most New England homes were painted with lead-based paint well into the 20th century, and strict regulations have resulted in the de-leading of thousands of homes each year. The workers who do this de-leading have blood lead levels measured every few months and are referred to the clinic for assessment of an elevated level. It was our role to determine if they were actually lead-toxic and whether or not chelation therapy was indicated.

Another common problem involved asbestosis due to workplace exposures several decades ago, often in construction or shipyard workers. While I was there, Harvard Medical School hosted the biannual conference titled Current Concepts in Asbestos-Related Lung Disease, with a participant list of physicians, technologists, defence lawyers, and prosecutors. The weekend was a mix of basic science, clinical vignettes, and an overview of the legal ramifications of asbestos-related illness.

Thursday afternoons were the most intriguing, consisting of self-referral clinics for patients concerned they had been exposed to toxins in their environment. For example, one patient’s home had been sprayed with a particular pesticide in the late 1970s that has since been banned and regulated as a carcinogen. He had already consulted a private environmental firm that sampled his house and found that it did indeed contain an “elevated” level of this substance (i.e., a concentration above the recommended safety threshold). This patient had recently been having episodes of lightheadness, paresthesias, and forgetfulness and came to us asking if his neurological symptoms could be caused by this toxin in his home. I got to research the chemical’s structure and kinetics and find all available information on health effects. Interestingly, the effects of many regulated chemicals have been studied primarily in animals, and it was interesting to work through the extrapolation process. This particular pesticide, for example, had been shown at extremely high concentrations (100 times the concentration in his house) to result in abnormal liver enzymes in rats. An “uncertainty” factor had been applied, and the safe threshold for people was grossly estimated with absolutely no human studies on record. His home did have an elevated concentration per se, but the clinical relevance to his health was virtually nonexistent.

Cases like this were actually satisfying in that we could reassure the patient that his symptoms were not caused by this chemical exposure. The aforementioned environmental consulting firm also offered decontamination processes that cost tens of thousands of dollars, so we may have helped him conserve his life savings. And, as internists, we had the skills to actually identify the underlying problem and send the patient down an appropriate route for investigating his health complaints.

Hybridizing toxicology and clinical medicine, I believe the field of OEM will continue to flourish over the next several years and the need for skilled practitioners will continue to grow. The Harvard School of Public Health (HSPH) offers a range of graduate courses in environmental health and, furthermore, offers a 2-year fellowship program in OEM that includes 1 year of clinical medicine and a 1-year master’s degree. Their trainees come from diverse backgrounds including internal medicine, family practice, and emergency medicine, and this program leads to board certification in OEM.

I would like to thank the HSPH, Ann Backus, Dr. Stephen Kales, Dr. David Christiani, and Dr. Jonathan Holder for their teaching and their time – this was an incredible learning experience.

Article Citation: Johannson K. The Boston Experienc. Can J Gen Intern Med 2008;3(4):183