The impact of lifestyle (e.g., diet, physical activity) on health and the role of behavioral factors in disease (e.g., smoking, alcohol and other drug abuse) is generally recognized. The impact of one's occupation is becoming more widely appreciated in recent times, but is linked to antiquity. Observations of illnesses of workers date back to Hippocrates who wrote about lead poisoning in the 4th century B.C.1 The counsel of Hippocrates to physicians regarding the initial patient evaluation was: "when you come to a patient's house, you should ask him what sort of pains he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats". In 1770, Bernardino Ramazzini, author of De Morbis Artificum Diatriba (Diseases of Workers) observed: "I may venture to add one more question: what occupation does he follow?"2 Ramazzini is regarded as the father of occupational medicine and producer of the seminal work in what was to become the specialty of Occupational Medicine.
In 1950 the World Health Organization elaborated on the concept of occupational health: "occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well being of workers in all occupations; the prevention among workers of departures from health caused by the working conditions; the protection of workers and their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological equipment; and, to summarize: the adaptation of work to man and each man to his job."1
Significant progress has taken place in occupational health in the past 5 decades. Occupational Medicine became a recognized specialty, occupying a position with Public Health and Aerospace Medicine under the American Board of Preventive Medicine in 1955.1 Based upon the principles of preventive medicine, the broad purpose of occupational medicine is the promotion and maintenance of the physical and mental health of people at work.
The American College of Occupational and Environmental Medicine (ACOEM) has over 7000 occupational medicine physician members and identifies its mission as promoting worker and environmental health through preventive medicine, clinical practice, research and education.3 Occupational medicine practitioners who are Board certified in other primary medical specialties are eligible, after meeting other educational and experience requirements, for Masters and Fellow status in the College.
As noted by McCunney,4 the success of any business depends ultimately on the quality of its human resources, or employees. Occupational medicine provides tools for the preservation and improvement of these resources. The relationship of employee health to economic factors has assumed special emphasis in the business climate of the `90's, marked by attention to all factors which contribute to the "bottom line". Work related injuries and illnesses can be a significant economic burden, both in insurance costs and in loss of productivity. Acute trauma remains the most common health business problem but cumulative trauma disorders are one of the fastest growing types of workers' compensation claims.4 Physicians can assist employers in minimizing fraud and reduction of expenses through case management. Case management approaches can also be applied to non-occupational injuries and illnesses in order to facilitate employees return to work. Medical input can also be invaluable in dealing with the requirements of the Americans with Disabilities Act, as discussed below.
Beginning in 1994, all physicians desiring to treat injured workers have been required to take an education course approved by the Division of Workers' Compensation (those treating 12 or fewer annually and anesthesiologists, radiologists and pathologists are exempted).5 Although the merits of this requirement have been widely debated, it illustrates the concern of employers and the Florida legislature that physicians have a basic appreciation of some of the prevention and management aspects of work-related medical conditions. An approved 5-hour course addresses: 1) cost containment; 2) ergonomics; 3) practice parameters; 4) utilization control; and 5) return to work. The objectives of the course include improved physician identification of work activity factors relating to injury, appropriate treatment and physical restriction assignment, and reduction of unnecessary lost work time.
For some years, practitioners both inside and outside of occupational medicine have posed questions about the uniqueness of the specialty. In response, in 1994, ACOEM established an ad hoc committee to review the practicality of developing competencies for the practice of occupational and environmental medicine. A panel on Competencies in Occupational and Environmental Medicine was created and the "Occupational and Environmental Medicine Competencies, Version 1.0" was approved early this year and will be published in May, 1998 in the Journal of Occupational and Environmental Medicine.3
An executive summary of this report states: "Occupational and Environmental Medicine (OEM) is devoted to the prevention and management of occupational and environmental injury, illness and disability, and the promotion of health and productivity of workers, their families and communities. Through training and experience, the OEM physician possesses the specific knowledge and skills - competencies - to achieve this mission." It observes: "Generalist OEM physicians - those who primarily manage occupational injuries and fitness for duty issues - will have a strong clinical emphasis and will be familiar with issues of work placement and accommodation. In addition to this grounding in clinical practice, specialist OEM physicians will have competencies in public health, prevention, population medicine, epidemiology, toxicology, research methods, etc." Further, "Whether a generalist or specialist, all OEM physicians must be able to both apply the fundamental principles of prevention and public health to clinical practice and vice versa."3 In brief, the major goals of occupational medicine are prevention of occupational illnesses and the treatment of injuries that occur in the workplace.
The employer's responsibility for the employees health and safety is regulated by Federal and State government. The Occupational and Safety and Health Administration (OSHA) and the Florida Workers' Compensation Statutes establish the scope of the employer's requirements. Central to the Occupational Safety and Health Act of 1970 is the General Duty Clause, which requires employers to provide a place of employment "free from recognized hazards".3 In Florida, the Workers' Compensation law requires that the employer provide a safe workplace.6
Several specific OSHA standards require involvement by physicians. Medical examinations prior to the performance of the duties of certain jobs are required; e.g., evaluation of physical fitness to wear respirators is required by the Respirator Protection Standard. Physicians are needed to comply with standards which address certain medical surveillance services relating to chemical and other environmental hazards. The physician who is informed and utilizes occupational medicine resources can make a significant contribution to injury and illness prevention and can assist the employer with risk reduction and employee health cost savings.3 The specialty can serve as a resource to the non-occupational physician in dealing with occupational issues for his or her patients.
The scope of Occupational Medicine Services is outlined in Table 1.4 The most common preventive occupational medicine services fall into the categories of 1) preplacement examinations 2) work injury or illness evaluation and treatment 3) medical surveillance examinations and 4) health promotion.
Table 1. Scope of Occupational Medical Services |
|
The preplacement examination is performed after an applicant has been offered a job by the employer. This examination is distinctly different from the "pre-employment examination", which often served in the past as an arbitrary obstacle before an applicant was offered a position. With the enactment of the Americans With Disabilities Act, the "pre-employment examination" is no longer permitted.1 The content of the pre-placement examination depends on the job and essential functions. The essential functions must be understood by the examining physician and ideally further identified through a worksite assessment. The examinations can then be performed with an understanding of the essential duties, physical requirements and potential exposure to hazardous materials. Following the examination, the physician makes a determination concerning the applicants ability to perform the job in a manner which does not pose a health or safety risk to himself or others. Thus, the ADA protects the applicants from discrimination based upon disabilities, and allows the physician to assist the employer in reducing the risk of physical injury and illness to employees.
The goal of medical surveillance is to prevent work-related illness through early recognition of problems, such as abnormal laboratory test results that may be associated with the initial stage of disease. Such exams are required by some (and recommended by others) OSHA standards (eg;asbestos, lead). The specific type of occupational health services appropriate for any employer depends on the nature of its business. An industrial hygiene review can address chemical agents which may have potential health risks because of carcinogenic or toxic health effects, physical agents, such as noise, radiation, heat and cold, biologic agents, such as fungi, bacteria or viruses, and ergonomic stresses resulting from repetitive motion activities.1
The physician treating patients who are injured at work or attribute illness symptoms to work activity or environment (e.g., occupational dermatitis, asthma) plays an important role in the management of Workers' Compensation cost, especially in the assignment of meaningful restrictions, approval of modified duty or alternative assignments, and coordination of rehabilitation services. The physicians can also alert the employer to considerations which may prevent future occurrences. For example, the suspicion by the physician that an employee's tendonitis might be related to work activity which is awkward, forceful or excessively repetitive, can prompt the employer to make the needed ergonomic changes ( i.e. changes in the work angle, height or depth, or job redesign or rotation). Physical and occupational therapists can provide valuable assistance to the physician in identifying physical demands of a particular job and in recommending and communicating ergonomic changes to the employer.
Chronic back disabilities account for approximately 80% of the costs for back injury conditions. These can often be prevented through early, aggressive management involving physical therapy, elimination of unnecessary bed rest (no more than 2 to 4 days with the most severe cases of strain) and early return to work.7 The injury category of sprains and strains in Florida, which includes acute and chronic non-surgical back pain disorders as a major component, is the leading category in total benefits by nature of injury between 1987 and 1996, accounting for 45.8% of all work injury and illness conditions.8
It is logical to argue that optimal health reduces absenteeism, disability, employee turnover and direct health care costs. Health promotion and wellness programs educate people on the adverse affects of certain lifestyles (e.g., cigarette smoking, lack of exercise) and can be a valuable contribution to support the objective of a health conscious, productive work force. Some studies have demonstrated significant evidence of the predictability of employee injury occurrences, with high occurrence rates correlated with low estimated relative maximum aerobic capacity (a measure of cardiovascular performance) and high percentage of body fat.9
By Florida law, effective January 1, 1997, all employers must provide medical treatment for work related injuries and illnesses through managed care arrangements approved by the Agency for Health Care Administration.6 Generally, a managed care program seeks to deliver quality care in a cost effective manner, to eliminate unnecessary services, and to prevent excess, uncoordinated use of medication, radiological services, and other medical services. Managed care arrangements strive to achieve this through a network of providers by setting the objectives for health care, communicating among the parties and monitoring and controlling healthcare delivery.10 The injured employee chooses the primary care provider within the managed care arrangement's network of providers. The employee may make one change to another physician within the same specialty and provider network. Any additional changes are through grievance procedures. Managed care plans must have a sufficient number of providers and sufficient number of categories to assure prompt, convenient and after hours care. Designated physician gatekeepers known as Medical Care Coordinators within plans must M.D.s or D.O.s. A designated Medical Care Coordinator within a managed care arrangement has primary responsibility for case management.6
Workers' Compensation Managed Care Arrangements are required to use treatment protocols which are developed by the Agency For Health Care Administration. By statute, protocols which focus on the top 10 Workers' Compensation diagnoses, including low back injuries, are to be developed. Low back pain or injury and neck pain or injury guidelines were endorsed in 1996. Guidelines for injury or painful conditions for the shoulder, wrist and hand, knee and foot and ankle are scheduled for development. The guidelines are to focus on scientifically demonstrable, effective treatment and efficient utilization resources. They must be used by insurance carriers to identify overutilization and underutiliz-ation.10
| Table 2. Examples of the Interface of Occupational Medicine With Preventive Medicine and Managed Care | ||||
| Preventive Medicine or Managed Care Issue | Impetus | Relevant Medical Service | Potential Employer Economic Gain | Certification, expertise or designation |
| Medically Safe worker placement | Americans with Disability Act | Preplacement Examination | Accident or illness risk reduction | Knowledge of medical provisions of ADA and physical demands of work |
| Cost-effective treatment of injured or ill employees with return-to-work focus and prevention of future occurrence | 1993 Florida Workers Compensation legislation providing for managed care arrangements OSHA | Coordination of primary and specialty care | Reduction of
indemnity benefits Accident or illness risk and litigation reduction |
Medical Care Coordinator |
| Illicit Drug Use | Federal and State Drug Free Workplace Regulations | Review relevant biomedical information to determine presence or absence of legitimate use | Enhanced
productivity Accident or illness risk reduction |
Medical Review Officer |
| Disability status and Impairment Rating Determination | Workers' Compensation and disability benefits consideration | Evaluation and impairment assignment; disability management | Benefit payment savings | Independant Medical Examiner |
| Health Promotion | Employer's mission for healthy company, healthy employees | Disease detection (e.g. hypertension, depression, diabetes) eduation (e.g. smoking cessation, diet, exercise) | Accident or
illness risk reduction Benefit payment savings |
Medical Director or Medical Consultant for onsite service |
An overview of the occupational medicine aspects of preventive medicine and managed care is presented in Table 2. Contributions that physicians can make in the prevention of work-related injuries and illnesses center around:
| Resources | |
| American College of Occupational and Environmental Medicine | 1-847-228-6850 www.acoem.org |
| Florida Division of Workers' Compensation | 1-904-488-3431 www.wc.les.state.fl.us/DWC |
| Duke
Occupational and Environmental Medicine |
http://gilligan.mc.duke.edu/oem/ |
| Florida Workers' Compensation Institute | www.fwciweb.org |
| Florida Managed Care Institute | www.fmciweb.com |
| Leopold RS. 1997 Occupational and Environmental Medicine Internet Companion OEM Press. 1997 | 1-800-533-8046 |
| Levy BS, Wegman DH, eds. Occupational Health: Recognizing and Preventing Work-Related Diseases, 3rd ed. Lippincott/Raven, 1995. | 1-800-638-3030 |
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