In this Aug. 15, 2019 photo, hay dries after a recent cut at Stoneridge Farm in Arundel, Maine. Credit: Robert F. Bukaty / AP

Maine doctors are having more conversations with patients about the risks of forever chemicals, but they are often difficult ones to have.

While studies have linked per- and polyfluoroalkyl substances, or PFAS, to several health conditions, direct links are elusive. The chemicals can also be found in agricultural land, water sources, food wrappers and clothing, so exposure sources are hard to determine.

But that is why health experts say that is why it is even more important for doctors to know how to talk to patients about the risks of exposure. A recently released federal report was the first guide to who should be tested for PFAS and the share of Mainers who qualify is likely to grow as the state investigates sites linked to contamination.

For Dr. Rachel Criswell, a pediatrician at Skowhegan Family Medicine who has conducted research on exposure through breast milk, the topic has become a more frequent one, especially for patients in Fairfield, where the federal government will review health risks linked to sludge spread as fertilizer in the town.

When it comes up, Criswell said she talks to patients about PFAS exposure as a long-term risk for other health factors. Those can range from decreased antibody response, high cholesterol, thyroid problems, decreased infant and fetal growth and increased risk of certain cancers.

The problem is that practitioners cannot always correlate conditions to exposure except in the few cases where people worked directly with the chemicals, such as firefighters who used foam with PFAS in it.

“It’s a hard leap to make” in most cases, Criswell said.

Linking health complications to PFAS exposure is a challenge being confronted with lawyers pushing a growing number of lawsuits. It is the central question in a mass tort action effort fronted by famed consumer advocate Erin Brockovich in Maine. Attorney General Aaron Frey’s office is also preparing a lawsuit against chemical companies.

Talking about PFAS sometimes means conversations without concrete solutions on how to manage someone’s care or how their future health will be affected, said Toby Ostrov, the medical director of Four Seasons Family Practice in Fairfield.

Regardless of whether an exposed person tests for levels of PFAS in their blood or not, he said practitioners are speaking more with patients about how to limit risks and to keep up with routine screenings and follow-ups.

“We welcome ongoing education on PFAS testing, exposure and long-term health outcomes, and it is our hope that with further research we will eventually have more specific guidelines for follow-up and management of patients exposed to PFAS,” he said.

Getting doctors up to speed on PFAS exposure could take time, said Gail Carlson, an assistant professor of environmental studies at Colby College, because they might not typically think about environmental exposure as a risk factor. While the effects of lead and arsenic exposure have been established for decades, PFAS risks have only become well-known recently.

A blood test can give people a sense of how much of the chemicals are latent in their bodies. They are not readily available in much of Maine. But getting as many people tested as possible is crucial and should be encouraged by doctors, Carlson said, because it will allow for better data around which populations might be at risk for health issues later.

“You can’t wait for the smoking gun because then you already have so much health damage,” she said.

Finding out that their family had levels of PFAS in their blood several times that of the average American was stressful, said Adam Nordell, a campaign manager with Defend Our Health and the owner of Unity’s Songbird Farm, where PFAS levels 400 times greater than the state’s interim drinking standard of 20 parts per trillion were discovered late last year.

It took a “significant amount of self advocacy” at first to convince doctors that tests were important since lab technicians did not know the test existed and doctors were not familiar with PFAS, he said.

“Be an advocate for yourself and keep asking questions,” he advised.