CHAPTER 28: Preparation of the Physician forOccupational Medicine Practice
For a medical specialty which has existed for almost three centuries, occupational medicine remains curiously unfamiliar to many physicians. Although it is one of the oldest boarded specialties, it has had a low visibility. Despite explosive growth over the last ten years, it remains a small specialty and is one of the few to experience a shortage in physicians. While it is one of the most dynamic and rapidly advancing areas of medicine most of its challenges and accomplishments are scarcely known outside the specialty.
Occupational medicine is that specialty which identifies, treats, and particularly seeks to prevent disorders related to one's work, and which promotes positive measures to improve the health and fitness of the working population. Physicians or health care facilities may choose to enter occupational medicine practice for a number of reasons:
1. Additional Source of Revenue
2. Additional Source of Patients for General Care
3. Need for Services in Community
4. Clinical Research
5. Education and Training
Chapter 4 discusses in detail the physician's role in the private practice of occupational medicine. The physician must be at least as well prepared in institutionally-based practice as for private practice. Often, physicians who are new to the institution, retiring, or seeking new roles are recruited to head occupational health services. The best of them can be very good indeed but seldom are they prepared for the challenges they will face in providing occupational health services. Indeed, often they do not have the insight to see where improvements might be made or to understand why their practice of occupational medicine is less than optimal. As in any aspect of medicine, a commitment to occupational health care is a prerequisite for a satisfying and satisfactory practice.
Relatively few physicians in North America (less than 1000 in the U.S. and slightly over 100 in Canada) have specialty credentials in occupational medicine. With so few, it is clear that for some time to come physicians will continue to move into the field from other specialties or from primary care practice. Those who do will find it challenging and rewarding if they are prepared and committed.
Preparation for Practice
Increasingly, primary care physicians are being exhorted to involve themselves in occupational medicine. How to do so is seldom described, however. A professional commitment to this field will yield handsome benefits but must be undertaken only after careful preparation and with an appreciation for the complex technical and social aspects of the field.
In recent years, several writers have advanced compelling reasons for physicians to become involved in occupational medicine, including a responsibility to give attention to an important determinant of many patient's health, the need to reverse earlier neglect, the substantial opportunities for creative research, the compatibility of occupational medicine with primary care practice, and the need to expand and improve the quality of occupational health care in community settings. It seems apparent that physicians other than occupational medicine specialists who choose to enter into this type of practice have a legitimate role and stand to benefit from the relative openness of occupational medicine as compared to other areas of medical practice. Concomittant with this opportunity, however, is a responsibility to apply the same professional commitment and standards to occupational medicine as have traditionally applied to aspects of other specialty fields, such as office gynecology, which fall within primary care.
Certain steps should be taken by every physician seeking to enter occupational medicine from another practice are:
Ideally, these steps should be taken in the order given. Often, however, the sequence is precisely the reverse. A hospital, group or clinic may decide to open a clinic using whatever resources are at hand, may then conduct a market survey to determine how to sell the service, and may finally put in charge a physician who may or may not have a clear idea of the objectives of the service and of the field as a whole. This is not recommended but it occurs more often than not.
The right way is to plan the service methodically, with informed leadership from the outset. Institutions that want to enter the field should be agreeable to allowing the physician to prepare for practice in a new field and should be prepared to release the physician from other duties while this preparation is underway. Initially, some assistance can be obtained from consultants who are knowledgeable about occupational health services but eventually it is necessary to have a local "expert" to direct the enterprise.
There are many ways to gain the specific expertise necessary for a successful and satisfying practice incorporating occupational health care. Some medical schools, such as the University of Cincinnati, have condensed "mini-residencies" in occupational medicine requiring a full-time commitment for several weeks. The Medical College of Wisconsin has developed a comprehensive, self-paced extension curriculum relying on tutorials, interactive computer systems, and proctored examinations to provide the equivalent of a year-long academic program for practicing physicians. Many medical schools and the major specialty organizations sponsor continuing education programs, any one of which is usually strong on either scientific or administrative aspects of practice but rarely both. Continuing education for nursing staff involved in the clinic or office is well worthwhile. Visits to the better clinics are worthwhile; conversations are likely to be more candid the farther from one's anticipated practice. Plant tours and visits to industrial sites should be made at every opportunity in as many industries and employers as possible in order to follow changing conditions in the workplace and to observe different industries. To stay current, one should read at least one of the major textbooks (preferably Rom's Environmental and Occupational Medicine) and should follow the journal literature (principally the Journal of Occupational Medicine and the American Journal of Industrial Medicine).
The objectives of the service are critical to its ultimate success but are seldom well-defined in the minds of physicians and health care administrators. If the primary objective of the occupational health service is as a source of financial revenue, it will be structured differently and have different expectations for performance than if it is set up to meet a community need or to support education. Even among services set up for profitable operation there will be differences in long- and short-term goals, which industries are targeted, and whether growth is to be rapid or sustained. If the objective of the clinics is to generate referrals, it will be staffed differently than if it is to be self-contained.
Considerable confusion - and often hard feelings - arise because the objectives are not spelled out, or because not enough communication has taken place among the affected parties. For example, in one typical case involving a large group practice the occupational health service was criticized by the specialists for failing to meet their expectations for referrals, by the family practitioners for creating complications in the satellite clinics because of the need for separating occupation from personal health services, by the administration for wasting time on providing preventive services that were not well compensated, and by the support staff for disrupting the comfortable routine. When the occupational health service brought in 1500 new patients and became responsible for more than 10% of revenues for the group, however, it showed that it had succeeded in its primary objectives of expanding the patient and revenue base of the group.
Review the Needs of Local Industry; Become Knowledgeable on Local Problems
Although industrial communities share many common occupational health problems, the special problems of local industry must be understood if the occupational health service is to be responsive. This means understanding the particular hazards of local industries, the relationships among major employers in the area, the organization and ownership of local industries, and the special features of the workforce with respect to ethnicity, level of education, socioeconomic class, and unusual patterns of disease prevalence. Such information can be obtained from local chambers of commerce, local newspapers, the reference sections of local libraries, schools of business, and by interviews with corporate leaders. One may think one knows a great deal about the economic base of the community but there are often surprises. The presence of one or two major factories may blind one to the reality that the local economy is as or more dependent on such things as automotive repair and servicing, fast food operations, agriculture, tourism (including hotels and motels), and even medical care. Of these examples, each results in a sufficient rate of injuries and illnesses to require occupational health services on a frequent basis.
Plan the Proposed Service; Identify Resources
In planning an occupational health service, it is critical to identify essential roles and staff positions and then to fill them with the most qualified and suitable people available. Too often, positions are defined around the perceived strengths or limitations of the staff available, who enter their new positions unchallenged and without a formal job description and who then - in the absence of guidance - merely recreate their old roles and habits. This is not fair to the staff and counterproductive to the goals of the facility. Another problem is that occupational health services are often started up using bits and pieces and spare personnel from other units. There is nothing wrong with reusing good equipment and reassigning employees who have shown their worth, but the occupational health service must never be a dumping ground for old inventory and redudant personnel.
There should be a sense of mission about the occupational health service. It should play an important role in the life of the community and inside its home institution. The physician running it should be seen as a pioneer, not an outlaw. Too often, the job has been given to an otherwise qualified and well-meaning but poorly prepared physician or surgeon, often about to retire. The occupational health service is poorly served by such actions and will never reach its potential unless its leadership is strong, committed, and commands respect.
Occupational Medicine Practice
In practice, most occupation-related disorders are injuries on the job. These, and the performance of periodic health examinations, are usually what is meant by the now-obsolete term "industrial medicine." Occupational medicine embraces those functions and the management of occupation-related diseases, and places further emphasis on the prevention of health hazards in the workplace and on strategies for health promotion. The types of medical cases typically encountered by the occupational physician include dermatological problems, eye conditions, respiratory disorders, poisonings due to hazardous chemicals, cancer related to work exposure, and neuropathies. In addition, employee assistance programs supervised by the occupational physician may include alcohol and substance abuse rehabilitation and mental health services. Farsighted employers may also provide their employees with a variety of health promotion programs, such as fitness and exercise activities, smoking cessation, stress reduction, and weight control.
There are problems for the physician working in occupational health services. These include:
Some of these issues involve compensation for services rendered, although a well-managed occupational health service can be very profitable. More, however, reflect the lack of understanding encountered among other physicians and often health service administrators of occupational health services and of occupational medicine as a specialty or practice emphasis.
The world of occupational medicine is quite different from that of most other specialties. Most occupational physicians enter it from other practices, particularly family and internal medicine and general surgery. In many ways, occupational medicine is also a primary care specialty for employed adults. Academically, its board examination and training programs are handled as a subspecialty of preventive medicine. The practice of occupational medicine can be very disconcerting to physicians oriented to traditional primary care. Teamwork, administrative ability, and versatility play a greater role than in other specialties. Rarely does it take one into the hospital. The occupational physician soon finds that he or she depends on other skilled health professionals, such as occupational health nurses, safety engineers, and industrial hygienists (engineers trained in the recognition and control of health hazards in the workplace). Each of these professional groups has its own training, certification, and licensing arrangements; the occupational physician relies as heavily on these skilled professionals as a surgeon relies on the OR team.
The occupational physician must deal continually with strong economic, political, and social pressures even above the present complexities of medical practice. These include workers' compensation, disability claims, lawsuits, government regulations, labor-management relations, budgeting, and other issues far from usual office practice. A particularly challenging aspect is that the conscientious occupational physician must continually integrate new advances in toxicology, epidemiology, immunology, oncology, and clinical medicine, and must constantly explain his or her actions and thinking in basic lay terms.
Occupational Medicine as a Specialty
The past history of occupational medicine has been rocky. The specialty regularly cycles from respectability to apathy, often within a decade or two. It has had to live down past abuses and image problems, and a general perception of stagnation in the 1960's. The present cycle of expansion began in 1970, stimulated by an increased government role, the response of industry to rising costs, and certain scientific advances in toxicology and epidemiology. In past years, the emphasis in occupational medicine has shifted strongly in the direction of prevention and health promotion.
The expansion of occupational medicine practice has resulted in some unique problems as well as others common to its sister specialties. Among these has been the rapid and poorly monitored growth of occupational medicine facilities. Providing services to smaller businesses which cannot afford to hire full-time health personnel has resulted in an extensive proliferation of small clinics. Quality control has emerged as a major issue in occupational medicine, especially with few physicians available who are boarded or specifically trained in the specialty.
Although small as medical specialties go, occupational medicine is a rewarding and different challenge to the practitioner. Equally important to the practice of the occupational physician, however, is the recognition and appreciation by primary care physicians of occupational exposures and hazards as causes and contributing factors in illness and injuries.
The organized specialty of occupational medicine is now at a crossroads -actually a crisis - because the supply of trained and interested physicians falls far short of demand. A great expansion in the demand for occupational health services has led to a much greater involvement of other medical specialists and of primary care practitioners, including internists.
Physicians who have approached occupational medicine in a spirit of inquiry and discipline have found many opportunities for research and for a satisfying and demanding practice, particularly in academic and group practice settings. The key to success in this effort, however, is a willingness to learn the specific technical content of occupational medicine and to recognize the existing structure and institutions of the field.
Rosenstock L. Occupational medicine: too long neglected. Ann Intern Med 1981:95:774-776.
Guidotti TL. Occupational medicine at a crossroads. ACP Observer American College of Physicians, January, 1984; 4:5.
Graduate Medical Educational National Advisory Committee. GMNAC summary report. Hyattsville, Maryland: Health Resources Administration, U.S. Department of Health and Human Services, 1980.
ACP Department of Health and Public Policy. Role of the internist in occupational medicine: a position paper on the American College of Physicians. Philadelphia: American College of Physicians, 14 September, 1984.
Cullen MR. Occupational medicine. A new focus for general internal medicine. Arch Intern Med 1985; 145:511-515
Preventive Health Care Committee Society for Research and Education in Primary Care Internal Medicine. Preventive medicine in general internal medicine residency training. Ann Intern Med 1985; 102:859-861.
Guidotti TL. The general internist and occupational medicine. Gen Intern Med 1986; 1:201-202.