Don't lament, reinvent! The future of occupational medicine

Surveys on minimum practical abilities required by nonspecialist occupational physicians in Japan

OBJECTIVES

This study aimed to identify the practical abilities required by nonspecialist occupational physicians and specify the priorities for training programs.

METHODS

A practical abilities list was developed through a focus group meeting of specialists. We created a survey questionnaire and asked three groups, namely, occupational physicians, occupational health nurses, and health officers, to rate the importance of each practical ability.

RESULTS

The mean scores for all 45 items were greater than 4, i.e., in the middle of the 7-point Likert scale, for all the three groups. The occupational physicians' responses had a correlation with the other groups' responses. However, there were differences with regard to some practical abilities between the three groups. Five practical abilities from the top quartile were marked "A" by all the three groups: "Submit opinions on fitness for duty and work accommodation on the basis of data from health examination," "Respect employee privacy," "Submit opinion on fitness for duty and work accommodation on the basis of data from face-to-face interviews with employees," "Submit opinions on fitness for duty and work accommodation on the basis of data from health surveillance," and "Implement face-to-face interviews for employees who have worked overtime and evaluate the subjects' conditions including mental and physical health status, degree of accumulated fatigue, and depression."

CONCLUSIONS

This study resulted in a rank-ordered list of 45 practical abilities that are required by nonspecialist occupational physicians. This result may be useful to review and redesign the existing training program for nonspecialist occupational physicians.

Occupational and Environmental Medicine in the United States: A Proposal to Abolish Workers' Compensation and Reestablish the Public Health Model

The workers' compensation model of occupational and environmental medicine should be converted to a public health model. Occupational and environmental medicine, as a part of the public health infrastructure,could play a much more substantive part in bringing about a national program to deal with occupational and environmental health. The workers' compensation insurance system could be discontinued at any time,but it will be vital to do so when national health insurance is adopted in the United States. Abolishing workers' compensation would remove the perverse incentives that currently undermine the practice of occupational medicine. Medical care for workers should be provided by health care professionals who are not subject to influence by employers or insurers. Eligibility for benefits should not be determined by health and safety professionals. Wage-replacement benefits for workers should be determined by guidelines established by government and industry that prevent manipulation of health and safety professionals by employers and insurers. A nationwide comprehensive system to track work-related injury and illness, superior to the current reliance on records provided by employers and collated by government agencies, should be adopted. When unusually high rates of injuries, illnesses,and fatalities occur, government inspectors ought to respond and regulate the industry accordingly. Occupational health and safety professional strained in public health can and should participate in these activities, but not when they are in the employ of industry or insurers.

Historical development of the journal impact factor and its relevance for occupational health

For better or for worse, the advent of journal impact factors last century marked a key turning point in the global development of scientific publication and referencing systems. Since that time however, the concept has attracted considerable attention from a variety of sources, and its usefulness for relatively small research fields such as occupational health, has also been debated. For these reasons, the current paper provides a descriptive history of the journal impact factor and a discussion of its relevance for occupational health. Developmental milestones, inherent shortcomings and future challenges are also described, along with techniques used for increasing the impact factor and some potential strategies for improvement of the citation indexing system. While many scholars now question its increasingly prominent role in the evaluation of scientific research, the journal impact factor continues to form an important component in the dissemination and retrieval of scientific literature in the occupational health field, as elsewhere. Due to the controversy incurred since its inception however, and the increasingly diverse manner in which it is now being used, it remains to be seen what the next 50 years of journal impact factors will bring.

Occupational Medicine Physicians in the United States: Demographics and Core Competencies

OBJECTIVE

We assessed the demographic profile and opinions of current occupational medicine (OM) physicians on the importance of specific core competencies.

METHODS

A random sample of 1500 OM physicians listed in the membership directory of the American College of Occupational and Environmental Medicine (ACOEM) were asked to complete a voluntary survey.

RESULTS

Six hundred and ten OM physicians completed the survey. Fifty two percent worked in clinical settings, and 16% worked in corporate or industrial settings. Eighty percent were satisfied with their choice of careers.

CONCLUSIONS

OM physicians appeared to be highly trained, with 60% certified in OM and 68% board certified in other specialties. The OM physicians valued staying current in the field, understanding the relationship between occupational exposure and health, and communicating with stakeholders most highly. Occupational physicians are an important source of knowledge regarding what competencies and core knowledge areas are important for OM practice.

A conceptual model of work and health disparities in the United States

Recent research in medicine and public health highlights differences in health related to race, ethnicity, socioeconomic status, and gender. These inequalities, often labeled "disparities," are pervasive and pertain to the major causes of morbidity, mortality, and lost life years. Often ignored in discussions of health disparities is the complex role of work, including not only occupational exposures and working conditions, but also benefits associated with work, effects of work on families and communities, and policies that determine where and how people work. The authors argue that work should be considered explicitly as a determinant of health disparities. Their conceptual model and empirical evidence, built on previous contributions, describe how work contributes to disparities in health on multiple levels. The examples focus on the United States, but many of the key conceptual features can also be applied to other countries. The model emphasizes behaviors and characteristics of institutions rather than individual workers. This approach avoids a focus on individual responsibility alone, which may lead to victim blaming and failure to emphasize policies and institutional factors that affect large populations and systematically create and maintain racial, gender, and socioeconomic disparities in health.

Occupational medicine practice in the United States since the industrial revolution

OBJECTIVES

Occupational medicine lies at the interface between work and health. Not only do workplace hazards impact health, but our state of health influences our ability to get to work, to perform work, to tolerate work, and to gain a measure of satisfaction from the work we do. Comprehensive occupational medicine requires familiarity with the work that patients do; knowledge of the workplace itself and its hazards; appreciation of the social forces that shape work; and understanding of how chemical, physical, biologic, mechanical, and psychosocial agents influence health. Many practitioners who treat injured workers or provide disability assessments have no more formal training in occupational medicine than primary care physicians in general, which limits the quality, or at least the scope, of the care they give to workers.

METHODS

This history has been compiled from books, journals, letters and recollections. A subset of journal issues from each decade after 1910 has been systematically reviewed, making no attempt to read through every issue.

RESULTS

Industrial medicine as we recognize it began in the late-1800s, grew rapidly in the early and mid-1900s, and peaked toward the end of the 20th century, when American corporations began to outsource medical services, supporting the rise of free-standing industrial medicine facilities, chains of which now operate profitably throughout the country. Many of these facilities emphasize injury treatment, work hardening, and physical therapy rather than disease recognition and prevention. Occupational medicine is one of the very few medical specialties to be underserved. Board-certified specialists are relatively few, and when supply falls short of demand, the demand has tended to lower its sights.

CONCLUSIONS

Occupational medicine has always been influenced by economics, politics, and changing patterns of employment, and today these forces include managed care, weakened unions, outsourcing and contract labor, and a generally growing political and social conservatism, not to mention multinational corporations. The globalization of manufacture and economics facilitated by rapid population growth in poor nations assures an unending supply of cheap labor, allowing limited attention to hazard control, thereby impeding progress in occupational health and safety. Some corporations are meeting the challenge of protecting their international workforce. Many, probably most, have not yet achieved this.

Late industrial development and occupational health in southern Italy

The authors report the occupational medicine problems in the Apulia region, which are representative of those in Southern Italy. Late industrialization was associated with an early peak in injuries that was not associated with an increased workforce. Examples of operations adversely affecting worker and population health are presented.

Chronologic History of Occupational Medicine

OBJECTIVES

To provide a chronologic review of growing knowledge in occupational medicine relating work and work hazards to health, and to provide a perspective on the lessons learned from the frequent inattention or misrepresentation of hazards.

METHODS

Many books on the social and medical history of work including epidemiology and toxicology were reviewed, as well as published papers and interviews.

RESULTS

Throughout history workplace hazards and occupational medicine have been shaped by the forces that shape work itself, social evolution, changing modes of production, shifting economic powers, and demographic changes in the workforce. Lest we think these changes are unique to the present time, this paper emphasizes the long-term and inevitable relationship between social structure and worker health. Hippocrates emphasized the relation between environment (air and water) and health, although he has less to say about the non-military work environment, perhaps because of the denigration of manual labor in Greece. The impact of work on health can be traced to the Edwin Smith Surgical Papyrus, written approximately 1700 BC. The earliest occupational physicians served military forces, and Galen was physician to Roman gladiators. Finger and wrist guards worn by Bronze Age archers represent early personal protective equipment. Writers of the classic period mention diseases and hazards of miners, and Pliny (1st century AD) mentions veils to cover the face. In the Middle East Rhazes included occupation in his case studies (9th century). Paracelsus, and Agricola were prominent, figures in the 15th century, with an emphasis on mining and health. Ramazzini's (c1700) work was widely translated in ensuing decades and is now well-known to all, but its influence between about 1800 and 1940 is inapparent. The emergence of a public health movement in the mid-1800s focused attention on the abominable conditions of many factories and on the living conditions, poor nutrition, high stress, poverty and ill health of the new factory working class, while paying scant attention to specific workplace hazards.

CONCLUSIONS

The recognition of occupational diseases in the United States has often lagged by a generation behind the recognition of the same diseases in Europe. We are now into a second industrial revolution led by multinational corporations and information technology, shifting production facilities, and jobs moving around the world in search of cheap labor in the countries with the fastest growing population and the greatest poverty. Occupational medicine must be alert to the new challenges imposed by this revolution.

Fifty years of hope and concern for the future of occupational medicine

Recently, there has been considerable concern expressed from a number of sources about the future of occupational medicine. A review of the literature and other sources reveals that over the past 50 years there has been continuous hope and concern for the specialty. Occupational medicine became a certified specialty in 1955, growing slowly until 1970, when the passage of the Occupational Safety and Health Act, growth accelerated. The marked decrease in classic occupational diseases, injuries, and deaths is a major triumph but may also be a factor in declining interest in specialization by physicians. Potential conflicts of interest have been at issue for over 50 years. Occupational medicine is now mostly clinical, in contrast to previous years. However, occupational medicine is a distinct and solid specialty that still offers many challenges.