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Patient Attitudes Toward Issues
of Environmental Health (cont'd)

Discussion

Physicians currently attend to patients who have grown up exposed to familiar works on environmentalism such as Rachel Carson's Silent Spring and Dr. Seuss's The Lorax and have considerable interests in environmental issues (Baxter 1990). In addition, physicians are in greater demand to provide patient and community groups with information on environmental risks (Graber, et. al. 1995). Consequently, there have been a few recent reports signaling the responsibility of the medical community in addressing environmental problems as they relate to health (Rosenblatt 1997; Haines and McMichael 1997; McCally and Cassel 1990). The development of a four-dimensional ecobiopsychosocial perspective in the family practice literature has been proposed to acknowledge “the fact that the health of our patients and ourselves is affected by events that take place on a global scale” (Rosenblatt 1997). In this context, attention to environmental issues is essential.

Although primary care physicians are often the first contact for patients presenting with environmentally-induced illness (Sanborn and Scott 1998; Taylor and Ruth 1995), few studies exist evaluating physicians as sources of environmental health information (Sanborn and Scott 1998; Taylor and Ruth 1995; McCallum et. al. 1991) or the interests in environmental issues by primary care patients (Graber and Musham 1996). This study sought to describe the current environmental interests and attitudes of family practice patients.

Patients encountered in our family practice clinics were, in general, very interested in environmental issues, with most reporting that environmental problems had effects on their health and the health of their families. Issues of water, air, and food quality were at the forefront of their environmental concerns. Although the patients were slightly less concerned with radiation, population growth, biodiversity, and land use, these issues were of high interest as well.

Family physicians were seen by their patients as being moderately well informed about environmental issues in general and very well informed regarding their health effects. Despite that fact, only one in five patients had discussed an environmental issue with his or her physician. Likewise, surveys of residents in six communities across the United States (McCallum et. al. 1991) and in Canada (Sanborn and Scott 1998) have indicated that physicians were the least commonly used source of information on environmental risks.

Even though physicians were not readily utilized as sources of information in this study, they received the highest level of trustworthiness concerning environmental issues. Similar levels of trust have been documented regarding environmental risk information in a community survey (McCallum et. al. 1991). Results of a Health Canada survey (Sanborn and Scott 1998) have also documented the disparity between high trust and low utilization of the medical community as a source for information on issues of environmental health.

Most patients reported that they had received inadequate amounts of information and education from their physicians regarding environmental issues. Although some of these are not traditionally in the context of a medical visit (biodiversity, population, and land use), others clearly are (air, water, and food quality). Patients with children and patients in rural settings tended to report that they had received more information than other patient groups. These differences may be the result of routine lead screening with associated questions about the home environment that occur during well-child examinations and the day-to-day exposures of farm families to various agricultural chemicals. For example, a study of Australian physicians found that rural physicians were utilized twice as often for questions of environmental health than were urban colleagues (Taylor and Ruth 1995). Female patients and patients in urban areas tended to be more interested in receiving more environmental information.

Several limitations exist within this study. Although a reasonable response rate was obtained, some patients did not return the questionnaire or agree to participate in the study. It should be noted, however, that most patients refusing participation did so because they did not feel well or were preoccupied with children.

A bias toward overrating the general level of trust in doctors concerning environmental issues may be present. Because this questionnaire was administered in the waiting rooms of family practice clinics to patients awaiting their appointments, patients may have extended their trust of doctors on medical issues to environmental issues. Also, people found at the doctor's office probably trust their physicians more than people who do not visit their doctors when sick or for routine visits. Despite the potential bias, this study focused on the perspectives of family practice patients so that changes could be made within the clinic setting if appropriate.

Although the demographics reflected patient populations of each clinic, generalizability of this study to other geographical areas may be limited. Nevertheless, a comparable study of 343 elderly patients in six family medicine clinics in South Carolina (Graber and Musham 1996) produced very similar results in terms of patients' sources of environmental information, with television and newspapers cited as the most common major sources of information, followed by friends and environmental groups. The low utilization of doctors also closely resembled results found in this study. Moreover, respondents' major concerns were in good agreement with the results found here.

In summary, this study provides an estimate of family practice patients' level of interest and concern among several environmental issues, their major sources of information, and their trust in these sources. The majority of patients surveyed felt that environmental problems affect their health. It is reasonable to conclude that patients do perceive environmental health risks in their lives. They highly trusted their physicians' knowledge of environmental health issues. Doctors, however, were underutilized as a source of environmental education. Moreover, patients felt that they did not receive enough environmental education from their physicians, despite being a highly trusted source.

Factors that may contribute to this underutilization may be found in the lack of public policy directed to environmental health issues (Zeitz et. al. 1998) and the minimal formal training that physicians receive in environmental medicine and health(Sokas, et. al. 1993). Although medical students express interest in environmental medicine(Kasma-Ronkainen and Virokannas 1996), medical school curricula are extremely crowded (Graber, et. al. 1995; Graber and Musham 1995) with the average student receiving only four hours of instruction on environmental and occupational medicine over four years (Levy 1985). Thus, most physicians are inadequately trained to discuss issues of environmental health.

We believe family physicians and other primary care physicians should address the environmental concerns of their patients more often, offering information on how environmental problems may affect their health or the health of their families. An enormous opportunity exists within primary care medicine to embrace environmental health. From the perspective of medical school deans(Graber, et. al. 1995), no clear consensus emerged on which department (Occupational Medicine, Community Medicine, Family Medicine, or Internal Medicine) should teach environmental health. Regardless, more of this training needs to occur (Frazier et. al. 1999). Because patients with environmental health issues are often encountered in the primary care arena and because environmental issues have an impact on the biological, psychological, and social spheres of our patients, it may be time to adopt an ecobiopsychosocial perspective and capitalize on the high levels of trust that our patients bestow on us.

Acknowledgment The University of Wisconsin Medical School's Department of Family Medicine has provided funding for this project through the Summer Student Research Assistantship Program. We thank Bruce Barrett and Kristin Powell and the anonymous manuscript referees for their review and comments.

References