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17 STRATEGIES TO ADDRESS THE PHYSICIAN SHORTAGE There is a critical shortage of specialty-trained OEM physicians in communities, in academic medical centers, and in public health and related agencies. A severe shortage of front-line primary care physicians who are willing and able to care for patients with occupationa~y- and environmenta~y-re~ated illness also exists. To acldress these shortages, highest priority must be given to interventions that will increase the number of academic OEM specialists who are needed to train sufficient numbers of specialists and primary care physicians to care for a large and currently inadequately served population. The lOM subcommittee recommended the following strategies. Increase Interest in the Field The physician shortage in OEM cannot be addressed merely with interventions to increase the training and availability of specialists. An important component of the

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18 shortage must be recognized and addressed: insufficient efforts are not undertaken to enhance the attractiveness of OEM as a career option. Although the development of numbers of interested applicants to some training programs, a phenomenon that could worsen if further strong role models in OEM will likely be accomplished by increased training and availability of specialists, it is important that undergraduate and graduate medical trainees be exposed to OEM material. Fundamental OEM concepts should be repeatedly introduced throughout the pre-clinical and clinical years. For example, a validated OEM screening history should be routinely taught in courses about interviewing patients and a clear set of learning objectives in environmental health should be developed for the undergraduate curriculum. Strategies to remove the many economic, legal, and ethical disincentives to the practice of OEM, outlined in the initial lOM reporY, should be implemented. At the same time, national education efforts--by both the tederai government and medical schools--should be made to increase awareness about OEM and delineate the professional opportunities in this expanding field. . Establish Centers of Excellence The specialty of occupational and environmental medicine is developing during times of limited financial resources and with only a few academic programs currently able to bridge the public health and the clinical aspects of the field. A limited number of centers of excellence--10 to 15--that provide specializecl training and

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19 research in occupational and environmental medicine should be established in the near future. They could make the most of scarce resources and seize the opportunity to create a critical mass of qualified faculty, ancillary personnel, and facilities to train future academic faculty. By serving as foci for OEM training, such centers could speed the subsequent diffusion of faculty to other medical schools and residency training programs; a critical factor in achieving the longer term objectives of widespread occupational and environmental medicine training at the undergraduate and graduate ~eve! and in meeting overall physician manpower needs in the field. A major objective of these centers is the training of future teachers and leaders who are well grounded in the clinical, research and teaching components of occupational and environmental medicine. Each specialized center for training and research should be able to (~) develop a program that will attract students with prior or planned attainment of sound clinical training in a primary care specially (internal medicine, family practice, or pediatrics) who are oriented to academic careers; (2) maintain a productive research base to assure academic visibility of its faculty and research training opportunities for its students; and (3) provide training in the clinical care of a wide range of patients with potential occupationa~ly- or environmental~y-related exposures and conditions. Funding of these centers will require additional federal resources, some of which should be directed to support necessary training and faculty components. There is also potential for funding through partnerships among private sector founclations, organizations, industries, and state governments.

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20 Integrate Environmental Medicine with Occupational Medicine Training and Research Programs As defined earlier in this report, environmental medicine incorporates most but not all aspects of occupational medicine and also includes the effects of exposure to a broad range of physical, chemical, and biological agents encountered in the environment outside the workplace. There are at least three important differences between the fields: (~) different populations are at risk, with environmental medicine covering all ages in the population; (2) different levels of exposure and risk exist, with environmental exposures invariably lower, less welI-defined, and associated with a less welI-developed scientific clata base; and (3) clifferent legal and social attributes, e.g., different compensation mechanisms. There are also important similarities between the two fields. Both disciplines require the physician's skill in being able to characterize exposure and subsequent risks under varying degrees of uncertainty, and both rely on physician knowlecige in several broad subject areas that include toxicology, epidemiology, public health, ergonomics, and, to some extent, engineering. On the basis of these similarities, and the fact that it is the limited number of occupational medicine specialists who are usually called upon to address clinical environmental medicine questions, the committee recommends that the specialty of occupational medicine be formally expanded to include environmental medicine. Accordingly, efforts to deal with the physician shortage should seek strategies to train specialists with clinical, .

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21 research, and teaching experience in both environmental and occupational medicine. In order for the two disciplines to advance together, it will be necessary to modify existing didactic, clinical, and research training of future specialists in OEM. Curriculum in occupational medicine should be altered to draw case material from environmental medicine. For example, teaching industrial hygiene, the mainstay of exposure control in occupational medicine, will need to encompass a broader view of environmental control and technologies. The experiences of practicing occupational medicine physicians and industrial hygienists represent a valuable resource for curriculum design. Clinical training must also be expancled appreciably, particularly in those occupational medicine training programs that rely solely on workplace practice settings or industrial medicine clinics as clinical training sites. The clinical evaluation of patients with potential environmental conditions is vastly different from the practice of occupational medicine in these settings, which is largely comprised of pre-employment examinations, fitness and disability assessments, and the treatment of work-related injuries. Occupational medicine programs that offer training in diagnostic clinical evaluation of widely divergent clinical problems are most ready to make the transition to training in clinical environmental medicine. Indeed, many of these programs have already begun to respond to the demand from patients and physicians for this service. Finally, as part of the evolution of expanding the borders of occupational medicine to include environmental medicine, faculty and trainee participation in environmental

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22 medicine research must grow and become an integral part of specialized centers for training and research. Increase Funding for Faculty Development More funding is needed to strengthen existing academic occupational and environmental medicine programs and to assure adequate start-up resources for newly Rained faculty, particularly those engaged in cleveloping new areas of scholarly inquiry in occupational and environmental medicine. Career development awards in other disciplines, such as those in preventive pulmonary medicine and cardiology and the geriatric faculty development academic award programs, can serve as models for providing salary support and resources to persons committed to assuming leadership positions in occupational and environmental medicine in schools of medicine. The appropriate federal agencies, including the National Institute of Environmental Health Sciences (NIEHS), the National Institute for Occupational Safety and Health (NIOSH) and the Agency for Toxic Substances and Disease Registry (ATSDR), should establish comparable awards in occupational and environmental medicine. These awards shouIcl be for physicians, both tenured and in tenure tracks, for development of their expertise in occupational and environmental medicine. In the absence of ful~-fIedged OEM faculty specialists, funding is also neecled to address, in the short term, the initiation of training in occupational and environmental medicine in primary care residency training programs. Such funciing would allow academic faculty in primary care

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23 specialties to gain special competence in occupational and environmental medicine by participating in intensive training (usually 6 months to ~ year) at an academic center with demonstrated excellence in the field. In its earlier report, the committee pointed out the need for a strong research base to facilitate faculty development and integration within the traditional medical school context,. Time for OEM in the curriculum is not obtainable and residency programs have little likelihood of success without full-time faculty who can compete for valuable course time through their success as faculty members. Such success hinges on the usual criterion of research productivity, and thus an increase in extramural research support in OEM is of central importance to manpower development -- as well as being needed to protect the public against environmental and occupational hazards. Support Residency and Fellowship Training Funding is not presently adequate to support graduate training in occupational and environmental medicine. Only about one-half of available training positions have the necessary funding. Given the need to expand the number of available and funded training positions in OEM, a significant infusion of federal monies is needed in a field that is almost exclusively an outpatient specialty and generates relatively few patient care dollars. In order to maximize the limitecl additional funds likely to become available, support should be focused on those programs most likely to train academic OEM specialists.

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24 These training funds could be an important component of funding of specialized centers for training and research. Certification and Accreditation in Occupational and Environmental Medicine Occupational medicine as a specialty in the United States has as its historic academic base an identity with preventive medicine, medical school degree programs, and schools of public health. Certification of individuals is provided only by the American Board of Preventive Medicine, and accreditation of training programs is available through the ACGME's Residency Review Committee for Preventive Medicine. Environmental medicine is a fledgling fielcl with no certifying or accreditation mechanism. Only in the past decade has occupational medicine begun to gain a presence as a clinical discipline within medical schools. It was in this context that the initial lOM committee proposed exploring the possibility of offering certificates of Added Qualifications by the American Board of internal Medicine (ABiM) and the American Boarcl of Family Practice (ABFP) to diplomates in internal medicine and family practice who had advanced training or experience in OEM. The mode' for such an approach was the ABIM and ABFP practice of offering a certificate of Added Qualifications in the field of Geriatric Medicine. The subcommittee recognizes that implementing a similar program for OEM is not without controversy. Nonetheless, we recommend this strategy as an effective means to address the shortage of OEM clinicians who are needed as practitioners, consultants, and teachers, particularly in locations not readily served by

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25 academic medical centers. This strategy has the potential to increase interest in OEM among the large pool of primary care specialists by offering a second certificate to those board-certified specialists who participate in one additional year of clinical OEM specially training. tt should be explored by the appropriate boards, including the American Board of Pediatrics (ABP), ABIM, ABFP and ABPM. The subcommittee also recommends an alternative approach to certification of the fulI-fIedged OEM specialist, a streamlinecl dual certification program by a primary care specialty Boarcl (ABIM or ABFP) and by the American Board of Preventive Medicine. This process has been adopted by ABIM in three areas, with the American Boards of Pecliatrics, Emergency Medicine, and Physical Medicine and Rehabilitation. Figure 3 outlines two pathways by which candidates would quality for examination by both the ABIM and ABPM; the first is currently available, and the second is an alternative approach that couIcl shorten training with cooperation of the respective Boards.

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26 Figure 3. Pathways for Admission to Examinations In Internal Medicine and Occupational Medicine Current 1 1 R-1 IM R-2 IM Alternative Pathway 2 L PGY- 1 R-3 IM Academic Practicum Practice Year - OM Year - OM Year - O IM Exam R-1 IMR-2 IM IM ~Academic OM OEM Clinic PGY - 2 R = Residency Year IM = Internal Medicine PGY = Postgraduate Year 1 OM Practice Year - OM 1 IM Exam OM OEM= Occupational and Environmental Medicine 0M = Occupational Medicine Practice year includes clinical practice, full time faculty, or research in occupational medicine. 2 If Residency Review Committee Preventive Medicine accepts a continuing weekly clinic in OEM throughout PGY 2-4. 3 Up to six months of internal medicine may be allocated to another discipline, such as occupational medicine.