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3 INTRODUCTION Public concern over potential hazards to health from exposure to chemical and physical agents in the environment has increased remarkably in recent years. Moreover, concern is widespread that the health care system in the United States is unable to respond adequately to the perceived or actual consequences of toxic occupational and environmental exposures. To address those issues, the Institute of Medicine (NOM) of the National Academy of Sciences convened a committee in 1987 to examine the rote of the primary care physician in occupational and environmental medicine and to offer recommendations to foster physician involvement in occupational and environmental health. In its report, The Role of the Primary Care Physician in Occupationa/ and Environmenta/ Medicine, ~ the fOM committee identified three specific problems: a shortage of specially-trained physicians to serve as teachers, researchers, and consultants to practicing physicians;

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4 . a lack of readily accessible information on toxic substances in the workplace and the general environment; and barriers in medical education and clinical practice that limit physician involvement in the area, inclucling the perception that occupational and environmental health conditions are infrequent, difficult, and time-consuming to diagnose and treat; the existence of significant economic disincentives such as the fragmented and often adversarial workers' compensation insurance system; and the pervasive presence of complex ethical and legal issues. The lOM committee recommended that "ail primary care physicians be able to iclentify possible occupationally or environmentally induced conditions and make appropriate referrals for follow-up". ~ To achieve that minimum standard of care, the committee concluded that all physicians must know some basic principles of occupational and environmental medicine, know how to take. an appropriate occupational and environmental history, understand the physician's role in the major workers' compensation systems, be aware of the ethical, social, and legal implications of the diagnosis of these conditions, and know when and how to report hazards to public health and regulatory authorities. In 1988 the lOM convened a new committee to assign priorities and develop specific strategies for implementing the first commidee's recommendations. A subcommittee was formed to address the physician specialist shortage

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5 and the concomitant deficiencies in undergraduate and graduate medical education. This report is based on the deliberations of that subcommittee. It includes observations of participants at a workshop convened by the subcommittee in 1989 and amended by specialists in internal medicine, family practice, pediatrics, and occupational and environmental medicine, as well as by representatives from government agencies and private foundations. It makes a series of specific strategic recommenclations for alleviating the physician shortage in occupational and environmental medicine. For the purposes of this recort. the following - . . , _ definitions of occupational and environmental medicine (OEM) were employecl. Occupational medicine is at' aspects of the relation between workplace factors (including physical, chemical, biological, social, and psychological) and health, with emphasis on the effects of work on health. Environmental medicine incorporates most but not all aspects of occupational medicine, and encompasses conditions caused or aggravatecl by exposure to (~) toxic chemical substances, such as formaldehyde and asbestos, that are either man-made or become biologically available as a result of human activities; (2) physical agents, such as radiation or noise, that occur naturally or as result of human activities; and (3) biological substances, such as LegionelIa spp. in heating and ventilation systems, that become problems as a result of human activities. 2 The domain of environmental medicine also includes the psychological burden of anxiety and concern about environmental *A second subcommittee on information systems was formed to address the issue of Meeting Physicians' Neec/s for Mec/ica/ /nformation on Occupations and Environments (/nstitute of Medicine, 79909.

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6 hazards--concerns that in some cases outweigh the direct biological threat. Environmental medicine excludes health effects of such behavior as active cigarette smoking, but includes exposure to a wide range of non-occupational physical, chemical, and biological factors (Figure 1~. Figure 1. Confluence of Occupational and Environmental Medicine ENVIRONMENTAL / MEDICINE ~ /~ - Occupational Medicine: \ OCCUPATIONAL ~ MEDICINE V All aspects of relation between workplace factors and health. Environmental Medicine: Effects on health from exposure to physical agents and toxic chemical and biologic substances which may be natural or result from human activities.