Enhanced Skills Program: Clinical Environmental Health Fellowship Goals and Objectives

Goals and Objectives 2014-15


Concern about global warming and its impacts on health, accompanied by some severe weather events and a growing recognition of increased prevalence of multiple chronic, complex conditions now scientifically linked to environmental exposures, have made medical fellowship training in clinical environmental health increasingly relevant.

The CEH Fellowship will include clinical work in the provincial Environmental Health Clinic, Toronto, and, as feasible, in collaboration with Ontario community clinics and public health departments. It will also include a combination of further academic training (e.g. accredited continuing education rounds/courses/conferences in environmental health (in Canada and the United States), one or more relevant research projects, and a presentation.


The Clinical Environmental Health (CEH) Fellowship will use as a framework the Triple C Competency-based Curriculum, including comprehensive care and education, continuity of education and patient care, and will be centred in family medicine.

The fellowship will enhance the skills of family physicians through training and supervision by family physicians and other health care providers with experience in environmental health. They model consistent integration of environmental determinants of health across the lifespan into family medicine practice, in ongoing care for patients and community protection.

Although environment has been recognized by the World Health Organization as an important determinant of health¹, the United States’ National Academy of Sciences (NAS) has determined that environmental medicine is a “missing element” in medical education.² The NAS has delineated competencies in environmental medicine (for medical students), and these have been incorporated into the fellowship’s objectives.


The objectives for the Clinical Environmental Health Fellowship Program have been developed in accordance with the core values of the CanMEDS-FM Framework of the College of Family Physicians of Canada. By the end of the fellowship, the fellow will be able to:

As a Medical Expert:

Demonstrate knowledge of the currently available scientific evidence regarding the links between environmental exposures and health conditions, as well as genetic, developmental, nutritional, social and financial vulnerability factors, to enable primary prevention or early intervention and secondary prevention of environmentally related illnesses.

  1. Elicit an appropriately detailed environmental exposure history, including a work history, and a comprehensive chronological clinical history, and do an appropriate physical examination.
  2. Evaluate functional status using questionnaires—the eight functional domains of the validated RAND Short Form 36 questionnaire, the validated Fibromyalgia Impact Scale and Fibromyalgia Impact Scale Revised (if widespread pain is present), and sleep, pain, energy, and activities through clinical questions or logs.
  3. Interpret and investigate the potential influence of the environment and environmental agents on individuals or communities based on assessment and knowledge of relevant epidemiologic, toxicologic, and exposure factors.
  4. Integrate the symptoms, signs, and sources of exposure, and record diagnoses.
  5. Recognize the need for specialized consultation, and appropriately refer to knowledgeable professionals with the patient’s agreement, providing a return appointment date to avoid any possible patient perception of abandonment.
  6. Identify and access the informational, clinical and other resources and convey them to assist patients to progress healthwise.

As a Communicator:

  1. Demonstrate skills in informing, empowering, and motivating patients, from the time of first contact, to enable them to make health-related decisions likely to improve their health and quality of life, and also to protect themselves and their families from future ill effects related to exposure to environmental hazards.
  2. Discuss environmental risks with patients and provide understandable information about risk-reduction strategies in ways that exhibit sensitivity to patients’ language capabilities, health concerns (for example cognitive difficulties and severe fatigue), and socioeconomic status.
  3. Demonstrate relationships with chronically ill patients and their families/caregivers that model respect and autonomy and comprehension of the complexity of dealing with environment-related conditions.
  4. Apply the chronic care model to environmental health, supporting and enhancing efforts of patients with chronic, complex, environmentally-linked conditions to self-manage.

As a Collaborator:

  1. Work within an interdisciplinary team to address complex patient issues and collaborate with Ontario agencies, community clinics, and public health units.
  2. Assist patients with their needs for workplace accommodations, housing, income, and other supports.
  3. Effectively lead or contribute to the health care team; delegate and distribute tasks fairly; use time wisely; manage difficulties; resolve conflicts.

As a Manager:

  1. Participate in continually updating evidence-informed indications for diagnostic investigations and therapeutic goals/strategies for patients with environment-related health problems.

As an Advocate:

  1. Assess community needs and participate in the development of appropriate materials or programs to protect the health of citizens of all ages from exposure to environmental hazards.
  2. Interact with and value environmental or consumer support groups who aim to protect the environment.
  3. Interact with, value and advise patient support groups who aim to protect patient interests.

As a Scholar:

  1. Maintain and enhance professional activities through ongoing learning.
  2. Critically evaluate medical information and its sources, and apply this appropriately to practice domains.

As a Professional:

  1. Demonstrate familiarity with the ethical and moral issues related to environmental health, and how they link with the Canadian Medical Association Code of Ethics.


  1. http://www.euro.who.int/__data/assets/pdf_file/0011/116012/WA3095.pdf,WHO Regional Publications, European Series, No. 35 (accessed Sept, 23, 2013 and Apr. 15, 2014)
  2. Environmental Medicine: Integrating a missing element into medical education. http://www.nap.edu/catalog.php?record_id=4795, Pope Andrew M, Rall David P, Editors, 1995 (accessed Sept. 23, 2013 and April 15, 2014)