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Fifty Years of Hope and Concern for the Future of Occupational Medicine

2004; Lippincott Williams & Wilkins; Volume: 46; Issue: 2 Linguagem: Inglês

10.1097/01.jom.0000111605.18487.56

1536-5948

Harold R. Imbus,

Climate Change and Health Impacts

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 with 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. A program at the Spring 2003 American Occupational Health Conference was entitled “The Rise or Fall of Occupational Medicine: The Future of Occupational Medicine in the 21st Century.” Some panelists participating in the discussion were optimistic about future opportunities in occupational medicine. Some were not. Altogether, it was a mixed review. The stimulus for the program appears to have been several recently published articles. In a somewhat gloomy scenario, LaDou 1 suggests that occupational medicine is returning to its pre-1970 obscurity. A response to the LaDou article by a number of academic occupational physicians, although recognizing some of the problems, expressed belief that the specialty has significant potential for future growth. 2 Frumkin 3 also concurs that there is a decline of occupational medicine but believes it is the result of major historical trends and recommends that the specialty reinvent itself. In an earlier article, he suggests the number of residency programs be reduced. 4 A literature review reveals many journal articles over the past 50 years dealing with the hopes and concerns for the future of occupational medicine. Also, during this period, the subject has often been discussed, formally and informally at occupational medical meetings. This article reviews some of the hopes and concerns for occupational medicine over the past 50 years and discusses some of the relevant issues. Hopefully, this review and discussion may add some perspective to recent concerns for the future of occupational medicine. Occupational Medicine Before 1970 In 1952, The New England Journal of Medicine published a two-part article entitled “Occupational medicine,” written by Harriet Hardy, one of the great pioneers of occupational medicine in the United States. 5,6 In it she explained why she used the relatively new term, “occupational medicine” in contrast to “industrial medicine.” She indicated that occupational medicine, in contrast to industrial medicine, includes a vast field of occupational health that includes rehabilitation, preplacement examination, occupational psychiatry, the problems of the cardiac patient, the older worker in industry, and proper medical service in small and large plants. She proceeded to review medical literature pertaining to occupational diseases. She was concerned that this information was not available to physicians other than in specialty journals. In 1955 the American Board of Preventive Medicine recognized Certification in Occupational Medicine as a specialty. 7 As a medical student of the class of 1954 at the University of Cincinnati, I was introduced to occupational medicine as part of our preventive medicine training. Although these classes were hardly met with enthusiasm by the class of 1954, something stuck, and in 1958 I entered the occupational medicine residency program at the University of Cincinnati. At that time there were five newly established occupational medicine residency programs at Yale, Rochester, Cincinnati, Ohio State, and Pittsburgh Universities. 8 There was an optimistic enthusiasm, sometimes verging on missionary zeal, of residents and faculty for their newly recognized specialty. The hope for the future was high. The concern for the future of occupational medicine was the lack of sufficient numbers of trained physicians to provide these services to both small and large industries. Dr Robert Kehoe, director of the Institute of Industrial Health at the University of Cincinnati, often expressed concern that with the small size and number of occupational medicine residency programs, the need for occupational medicine services far exceeded the supply of qualified practitioners. In 1963, the journal Industrial Medicine and Surgery announced an award of $1000 for the most outstanding original article devoted to the topic “ the future of health in industry,” alias “the future of occupational medicine.”9 By the 1960s, occupational medicine as we know it today had become a vibrant but small new field. However, the request for the articles may have foretold a certain concern for its future and perhaps an identity crisis about the specialty, which still seems to exist today. The publication does not state how many articles were submitted but says they came from over half of the then-existing 48 states, in addition to foreign countries. Altogether, 10 thoughtful and futuristic articles were published. 10–19 Occupational medicine has been called an obscure specialty before 1970, 1 and in many respects it was both small and obscure. Nevertheless, this does not detract from the fact that the field had a core of devoted physicians who believed they had something special to offer. Residents were able to meet many of the early pioneers of field, and both residents and faculty were promoters of the specialty. They believed there was something different about this field. There were classic occupational diseases, silicosis, asbestosis, organic phosphate pesticides poisoning, berylliosis, lead poisoning, byssinosis, and others remaining to be conquered. Industrial Medicine and Surgery was published from 1932 until 1973. After 1973, it became Occupational Health and Safety, and though it originally devoted much to treatment of trauma, by the 1950s it had many articles devoted to occupational medicine issues. For example, in 1953, this journal had articles, the titles of which would be appropriate in today’s occupational medicine journals. In just one issue, there were articles about the pathologic effects of work in cold environments, 20 patch testing, 21 rehabilitation in industry of problem drinkers, 22 and the placement, protection, and rehabilitation of persons suffering from heart disease. 23The Journal of Occupational Medicine, now T he Journal of Occupational and Environmental Medicine, began publishing in 1959 and since has been devoted entirely to publishing about occupational and environmental medicine. The AMA Archives of Industrial Medicine began publishing in 1960, bringing to three the number of occupational medicine journals in the United States. There were two major associations for occupational physicians, The American Academy of Occupational Medicine, limited to full-time occupational physicians, and The Industrial Medical Association, which later combined, and evolved into the present American College of Occupational and Environmental Medicine (ACOEM). Much of occupational medicine practice before 1970 was limited to large corporations and academia. Many of the Fortune 500 corporations had full-time medical directors. Some felt (mistakenly) that occupational disease problems had been mostly controlled in large industry. 10 There was, however, concern for the vast numbers of small industries that had inadequate or no occupational medicine coverage. 17,24 In 1966, Howe 25 wrote that large industries’ occupational health practices are very good but not in small industry. The hope and concern for the future was in providing such services. Occupational Medicine Since 1970 The year 1970 is considered by many to be the year that ushered in a renaissance of occupational medicine. After the enactment of the Occupational Safety and Health Act of 1970, there was much optimism for the future of occupational medicine. 26,27 Newly developed OSHA standards for asbestos, lead, occupational noise exposure, and cotton dust required medical surveillance. The cotton dust standard, even before final publication, resulted in many textile companies hiring full time medical directors. Through NIOSH encouragement and funding, occupational Education Resource Centers were established and concomitantly residency programs grew to 40 in 1995. 1 However, the 33 years following OSHA has not lead to the “promised land.” Scandals were published 28 in the 1970s, which hardly lent to the credibility of occupational medicine. The work of Sellikof and Hammond revealed that diseases from asbestos exposure were far from controlled. 29 Labor unions, newspapers, and magazines often attacked the credibility of occupational physicians. Activist organizations, such as the Carolina Brown Lung association, Attacked industry and occupational physicians in relation to the byssinosis problem. The latter part of the post-OSHA period also saw a significant change in the nature of occupational medical practice. Heretofore, most full-time occupational physicians worked inside industry. The rapid development of occupational medicine and combined occupational medicine/urgent care clinics made the field quite competitive. Other factors, such as decentralization and globalization, resulted in loss of manufacturing jobs and outsourcing of medical services to clinics and consultants. As a result, most occupational physicians today are in clinical practice. Occupational Diseases: 50 Years of Hope and Concern In the 1950s occupational diseases were common. Acute inorganic lead poisoning was seen in many industries, silicosis in foundries, and coal miner’s pneumoconiosis in coal mines. Noise-induced hearing loss was rampant. Dermatitis was a common occupational disease. In 1958, at the University of Cincinnati, one of the first cases the incoming residents saw was a man with severe classic asbestosis. When the residents visited the insulation manufacturing plant where he worked, a totally uncontrolled cloud of asbestos permeated the building and floated onto everyone’s hair and clothing. Blood for determination of lead was sent to the Kettering Laboratory at the University from many areas, and levels well over 60 mg per deciliter were not uncommon. Acute solvent toxicity was common. Large industry, often supported by strong union involvement, had in the 1950s and 60s made considerable progress with the control of many of these classic occupational diseases, but they were still common in small- and mid-sized industry. In the 1960s and 70s byssinosis became a serious and very public issue. Those were both heady and turbulent days for occupational physicians. The problems were generally obvious. The solutions to the problems were available. There was an immense gratification to see problems created by asbestos, silica, lead, solvent, cotton dust exposure, and noise come under better control. In the 1970s the newly enacted OSHA established exposure limits and monitoring standards. The number of certified industrial hygienists grew, and their contribution to exposure evaluation and control of occupational disease was immense. Classic occupational diseases declined. Later, the export of many manufacturing jobs to foreign countries further decreased the occupational diseases of manufacturing in the United States. The decrease of these classic occupational diseases is a triumph of occupational health programs. However, ironically, it may have had a somewhat adverse effect on recruitment of physicians to the field. Physicians like to see obvious problems that have obvious solutions, and so occupational medicine became a field of medicine in which problems were less obvious, and perhaps a field less likely to appeal to young physicians selecting a specialty. Although occupational diseases are much less obvious now, it would be a mistake to dismiss occupational exposures as no longer a health problem. The OSHA lead standard and pre-OSHA control measures have greatly reduced cases of adult inorganic lead poisoning. However new studies indicate that there may be problems at biologic exposure indexes well below 40 μg/dL. 30,31 Likewise, the epidemic of noise-induced hearing loss has been markedly reduced. But some will still have hearing loss at the permissible exposure level. Add chemical exposure to noise, and risk of hearing loss may increase. 32 Classic byssinosis has become rare since the establishment of the OSHA cotton dust exposure standard. This decline in incidence occurred even before the recent massive loss of textile jobs in the United States. However, a longitudinal study published in 1991, 33 14 years after the cotton dust standard was in effect, revealed that cotton textile workers in yarn manufacturing, especially smokers, had larger annual declines in lung function than those exposed to less harmful dust working in slashing and weaving. This was despite general compliance with the OSHA standard. Add ergonomically related musculoskeletal disorders, issues with mold, and newly emerging infectious diseases, and it is apparent that there are still many more challenges with occupational diseases. These issues and many others raise perplexing questions of how to protect workers health while establishing feasible exposure limits combined with medical surveillance. The occupational physician is increasingly called upon to assess issues of the interaction of lifestyle and environmental exposure. When it pertains to the worker who may potentially be exposed to something that is aggravating a pre-existing condition, the easy way out for the nonexperienced physician is to prescribe a job change. This is often done without the physician having any real knowledge of the job exposures or potentially beneficial modifications. But in today’s employment market, how easy is it for a 55-year-old manufacturing worker with a high school education or less to find a “clean” job appropriate to his skills and education? Yes, the classic occupational diseases have declined, the obvious solutions have been applied, but no less important today are the skills of the experienced and trained occupational physician. Multifactorial causation of diseases in workers needs to be identified and put in proper perspective. Because of concerns from industry and legal issues, such will be challenging, 50 years of Concern with Conflict of Interest in Occupational Medicine One area of concern that has always clouded the future of occupational medicine is the issue of conflict of interest between physician, patient, and employer. In 1965, Stewart 34 lamented the lack of respect received by occupational physicians. He discussed the need for qualified physicians who recognize occupational diseases if the evolution of the industrial physician is to be one of ascent. Silver in 1966 stated “… These (Medical) departments, in industry and government, are far more skilled at suppressing the complaints of the employees about adverse conditions than they are at getting the condition corrected….”18 In 1976, Miles Colwell, at the Sappington Memorial Lecture, discussed the credibility of occupational physicians. He was concerned that “Many hard-working, sincere and once-credible physicians are now looked upon with suspicion.” Also he stated that “In spite of the many recent doomsday books and articles stating otherwise, there were many sincere people administering many good occupational health programs prior to the (OSHA) Act.”35 Later, in 1991 McCunney and Brandt-Rauf discussed ethical concerns in preplacement examinations, medical record confidentiality, and patient management. 36 Many of the early industrial physicians dealt primarily with trauma and workers’ compensation issues. Many were full-time employees of industry or received their compensation from third-party payers. Unreasonable physical standards for employment were sometimes established and endorsed by occupational physicians. Because the compensation of the occupational physician largely came from industry or workers’ compensation, the industrial physician was felt by some to be compromised or biased. Compensation for most practicing occupational physicians still comes largely from industrial sources. That is unlikely to change, short of large-scale overhaul of our health care system. Recognizing this potential conflict, ACOEM has established a code of ethics. Although the basic source of compensation for occupational physicians has not changed, it has changed drastically for physicians in other specialties. Virtually all practicing physicians are now compensated by a third-party payer. Therefore, there is now an inherent potential conflict of interest in all of medicine. Recently on an e-mail forum available on the Duke University Occupational Medicine web site (http://gilligan.mc.duke.edu/oem/), there was an ongoing discussion of the conflict of interest of occupational physicians. Some felt that the occupational physician should provide worker patients with written disclosure of their potential conflict of interest. However, if that is appropriate, then is it not appropriate for the surgeon to inform the patient that if he operates he will receive a substantial fee, whereas if he does not, he will only be compensated for an office visit? Should the provider who belongs to an HMO or PPO inform the patient that his or her prescribing practices and ordering of tests and other procedures are being monitored and potentially he or she could be dropped by the HMO or PPO if he or she orders too many branded versus generic prescription drugs, too many MRIs or other expensive procedures? Should the patient be informed that the physician’s group expects him or her to see a patient every 15 or 20 minutes? Indeed there are and always have been potential conflicts of interest in all fields of medical practice, and they are increasing, as are they in all other professions and human endeavors. Recent accounting scandals illustrate this all too well. Ethical physicians, whatever their specialty, are aware of these potential conflicts, and despite the pitfalls and occasional unethical physician, can and do provide care that is in the best interest of their patients while also being fair to the source of their compensation. Is There a Golden Age of Occupational Medicine? The past 50 years has seen much hope for a golden age of occupational medicine. Is it past or in the future? In 1963, Dr Clarence Selby, 37 a pioneer of US occupational medicine, in an interview stated that the 1920s was the golden age of industrial medicine. He lamented the fact that “The ‘Golden Era’ came to an abrupt end with the great depression that began in 1929.” Industrial medicine programs and physicians were discontinued, even though the need was just as great. Although there were practically no industrial hygienists, “The physicians themselves were medical industrial hygienists.” In contrast, Dr William Shepard wrote in 1964 “Never since the concept of occupational health was born has the outlook been brighter for its future.”10 He predicted that occupational health will ascend to its rightful place among the specialties and “medical counsel will become so valuable as to be almost ubiquitous in all employer-employee relationships and in all industries and businesses, both large and small.” In an even more optimistic futuristic scenario, Joyner in 1965 predicted the establishment of the “United States Services, Environmental Health” in 2010 that would provide adequate environmental health programs for virtually 100% of the workforce. 14 The prediction of an agency came far sooner in the form of OSHA in 1970 but also fell far short of the virtual 100% adequate coverage. Many felt that OSHA would usher in the golden age of occupational medicine. However, this turned out to be more hope than reality. The OSHA standards requiring medical surveillance were indeed a positive development. However, these were specification standards, to be applied as a cookbook. Not a single standard identified the need for a specialist in occupational medicine to perform the examinations or even to oversee the programs. In the beginning many companies sought specialists in occupational medicine to implement and oversee their programs. However, as the requirements of the standards became more familiar and the diseases they were meant to prevent became less common, much of industry turned to occupational and urgent care clinics and outside contractors. Some of these had the necessary knowledge, but many did not. Many new physicians are now involved in providing occupational medical services through clinics. One only need to monitor the Duke e-mail forum to be aware of their sincere concerns and attempts to solve problems. Hope and Concern with Training, Residencies, and Numbers of Occupational Physicians Thurber 24, in an article in 1973 decrying the lack of occupational health services for small plants, pointed out that in 1932 there were only 1102 physicians limiting their practice or giving special attention to occupational medicine. However, in 1970 there were 2713 with primary specialty and 2008 with secondary specialty of occupational medicine, or a total of 4721. Now, the AMA estimates that 10,000 physicians do some occupational medicine. Since 1955 2400 have been certified by the American Board of Preventive Medicine. Of these 1500 to 1800 are estimated to be currently in practice. Physician membership in the ACOEM, which represents many of those with sufficient interest in the field to join, is at approximately 4800. Although it is somewhat speculative to make comparisons from these numbers, it appears that the number of physicians practicing some occupational medicine has approximately doubled since 1970. Meanwhile, according to the US Department of Labor Bureau of Labor Statistics, the nonfarm workforce has also almost doubled, from 71 million to 130 million. However, employment in manufacturing, the traditionally high user of occupational medicine services, has decreased from approximately 18 million to 13 million during this period. The five residency programs in occupational medicine in 1958 grew to eight in 1970. 38 According to the AMA Graduate Medical Education Directory, 2002 to 2003, there were 36 approved programs. 39 Residency slots are often not filled, a number of programs have closed, and further closures are predicted. Frumkin in 1995 predicted there are too many residencies and only 10 to 15 are needed. 4 In the past, occupational medicine was often a secondary career specialty. A physician became interested in the field, and after a period of practice and study, obtained the necessary knowledge and experience to take the Boards and become certified. That path has now been closed for physicians graduating from medical school in 1984 and after. Now, with that path taken away, the question becomes whether occupational medicine can attract enough physicians to enter residency training as their primary specialty. Occupational medicine has become much more of a clinical specialty. Much of that clinical work involves examinations of essentially healthy people and primary care for injuries, important functions indeed, but unfortunately perhaps not so appealing to the young physician who has spent time in residency learning about toxicology, occupational diseases, and epidemiology. Is There a Future for Occupational Medicine? Occupational medicine has always offered a dimension beyond other specialties. It is a preventive specialty, not only focused on disease, occupational or nonoccupational, but also on environmental exposure, and rehabilitation. Lately, it is argued by some, and seems to have taken hold in industry thinking, that since occupational diseases are less common, and we have so many medical specialists, we don’t need the specialty-trained occupational physician. Why not have the orthopedist or physiatrist offer primary care to musculoskeletal problems, and similarly, the dermatologist, pulmonologist, allergist offer care as appropriate to their specialties, while leaving minor trauma and routine examinations to the occupational or urgent care clinic. This argument misses an important point. A medical specialty may be defined by 1) an organ system, for example, neurology, dermatology; 2) A type of disease, for example, oncology, infectious diseases, rheumatology, occupational disease; 3) the process used in evaluating and managing a medical problem, for example, radiology, physical medicine; or 4) a group of persons of certain characteristics, for example, pediatrics, gerontology, workers. In the case of occupational medicine, 2, 3, and 4 apply. It deals with occupational diseases. It uses certain processes, for example, evaluating industrial hygiene data and interaction between attending physicians, patients, and management. The group the specialty deals with is working people. Therefore, even if a medical problem is outside the occupational medicine specialty, occupational physicians, whether or not they are the treating physicians, are the ones who can link together all of the needs of the injured or ill worker. They know the workplace. They have knowledge of the medical problem. Combining that knowledge with that of patient needs, communication with the treating physician, and management at the workplace, they are in a position to effect a satisfactory outcome that may not be achieved by a unilateral approach. Residency-trained physicians, who seldom see the exotic problems that they learn about in the residency, can become frustrated. However, when difficult issues arise, that is where the occupational physician specialist can apply knowledge and experience not possessed by others. That is why occupational medicine still needs trained specialists who can consult with other clinicians, or with industry or labor, or government. Occupational medicine is a sound specialty. It is a specialty with a future. It needs occupational clinicians who, whether residency trained or not, will acquire knowledge and experience over time. Sources such as ACOEM training courses and the Duke e-mail forum provide outstanding information for experienced and inexperienced physicians alike. Unfortunately, the path to certification is now closed to most nonresidency-trained physicians. Perhaps that will change in time. True, there have been many world events that have affected occupational medicine. Globalization and decrease in manufacturing jobs are commonly cited. The control of classic occupational diseases is another issue, but as pointed out above they have not all been conquered; they are just less obvious and are often the result of interaction with common diseases of life. As Dr Edward Emmett so eloquently pointed out at the 2003 American Occupational Health Conference, occupational medicine provides an essential business service. To adequately provide such service requires experience and training. Unfortunately many businesses, and vis-a-vis their employees are not getting adequate service. This has been so during the 50 years covered in this article. It is so now. A physician must by law have special certification to provide medical review officer service for DOT-mandated drug testing. However, the physician need not have certification or any type of specialized training to manage an OSHA-mandated medical surveillance program. More recently, the licensed health care professional, has been given authority in OSHA standards to provide many services. This licensed health care professional can be any licensed physician, nurse, chiropractor, naturopath, physical therapist, and perhaps others. Industry would seldom have an industrial hygiene survey performed by other than a Certified Industrial Hygienist, but employers seldom ask anymore about the experience and training of their physicians. What can be done to address some of these issues? Both an increased demand for and supply of trained and experienced occupational physicians is needed. Demand can be improved by education of potential clients, marketing, and better government recognition of the specialty. Businesses, professional organizations, medical colleagues, and the public at large need to have better awareness of the special skills of the trained and experienced occupational physician. They need to know that their health and safety programs will benefit from the involvement of the occupational physician. They need to know that the occupational physician can provide workers’ compensation case management, not only as an attending physician, but also as a consultant. They need to know that a corporate medical director (part time or consulting for some companies) can assist management and workers with a wide variety of health issues. Although classic occupational diseases are not so much concern now, health problems of workers that affect their work and productivity are a serious issue. Occupational physicians should expand their horizons to deal with these issues. How to create this awareness and market our specialty within the economic means of a small profession is another matter. Expanded use of the internet may offer significant opportunities. Encouragement of occupational physicians to participate in a speaker’s bureau, inexpensive folders and brochures aimed at medical and nonmedical groups, and articles written for the lay and professional press, are some of the possibilities. The involvement of occupational physicians on relevant government committees may result in more recognition of our specialty in the standard setting process. Occupational physicians need to work closely with their occupational health teammates: nurses, industrial hygienists, safety professionals, physical therapists, and their professional societies. They are a team, not competitors. The outsourcing of occupational medical services away from the workplace has contributed neither to the health of workers nor to the health of the specialty. When the physician comes to the workplace, the threshold to the worker is much more easily crossed. Communication with management is eased. A job can be easily inspected for placement or to evaluate health hazards. Workers compensation cases can be managed, whether or not their care is outside. Even a part-time service that combines clinical and consulting services can be beneficial. Occupational physicians should sell this service, and will find it adds to their professional satisfaction. Supplying adequate numbers of trained and experienced occupational physicians is another issue. Four residency programs have been lost in the past year, and others are at risk. A residency program, like a steel mill, is not something that can be closed and reopened at will. Adequate funding is an important issue that needs to be addressed. The possibility of additional career paths for the occupational physician should be explored. For example, this author, over the years, has often had difficulty in finding suitably qualified experts in the occupational medical aspects of such specialties as pulmonology, dermatology, allergy, immunology, neurology, and psychiatry. True these experts exist, but they are few and far between. Most of the highly qualified specialists in their respective fields have little knowledge of occupational medicine or industrial hygiene. Few neurologists understand occupational toxicology. Few allergists are experienced in chemical allergy and hypersensitivity. It would seem that transitioning from an occupational medicine residency to a fellowship in one or more of the above specialties would offer an exciting professional career. The American Board of Preventive Medicine has already established occupational medicine subspecialties of toxicology, and undersea and hyperbaric medicine. Perhaps adding some other subspecialties should be explored. Instead of a single focus on occupational diseases, prevention of all diseases among working people and their families will become a key issue. Occupational health programs are cost effective, and offer an excellent approach to control of some of our major health problems, eg, obesity. Another example: occupational asthma has always been the concern of occupational physicians. More recently, it has been demonstrated that workplace programs to control allergy of all types can be beneficial to health and productivity. 40 Occupational physicians are the most well positioned to provide this service. Health promotion and disease control offer significant opportunities. 41 In conclusion, it appears that occupational medicine has neither risen nor fallen. Its sudden growth since 1970 may have exceeded the demand, if not the need, for its services. In modern parlance, perhaps it was “a bubble.” Hope and concern for the future of occupational medicine has existed for over 50 years, and will probably continue for over 50 more years. But a changing workforce has needs for occupational medicine, perhaps to a greater extent than before. Irrespective of how great or small the growth is, the specialty of occupational medicine will continue to be an important and challenging one.