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INSTITUTE OF MEDICINE REPORT OF A STUDY ADDRESSING THE PHYSICIAN SHORTAGE IN OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Subcommittee on Physician Shortage Committee on Enhancing the Practice of Occupational and Environmental Medicine . . DIVISION OF HEALTH PROMOTION AND DISEASE PREVENTION NATIONAL ACADEMY OF SCIENCES WASHINGTON, D.C. 1991

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee appointed by the members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported under a cooperative agreement through the U.S. Public Health Service, Centers for Disease Control/Agency for Toxic Substances and Disease Registry; National Institute of Environmental Health Sciences; and the Environmental Protection Agency (contract no. ATU30021~. Publication No. IOM 91-03 2101 Constitution Avenue, N.W. Washington, D.C. 20418 1991 by the National Academy of Sciences Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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COMMI1lEE ON ENHANCING THE PRACTICE OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Bernard D. Goldstein (Chair), Professor and Chairman, Department of Environmental and Community Medicine, UMDNJ/Robert Wood Johnson Medical School, Piscataway, New Jersey John A. Benson, cr., President, American Board of Internal Medicine, Portland, Oregon Joseph M. Canned, Corporate Medical Director, Mobil Oil Company, Princeton, New Jersey Linda Hawes Clever, Chairman, Department of Occupational Health, Pacific Presbyterian Medical Center, San Francisco, California Adrian L. Edwards, private practice, New York, New York Edward Huth, Editor, Annals of infernal Medicine, American College of Physicians, Philadelphia, Pennsylvania Philip J. Landrigan, Ethel H. Wise Professor and Chairman of Community Medicine, Director, Environmental and Occupational Medicine, Mount Sinai Medical Center, New York, New York Richard C. Reynolds, Executive Vice President, Robert Wood Johnson Foundation, Princeton, New Jersey Linda Rosenstock, Director, Occupational Medicine, University of Washington, SeanIe, Washington Bailus Walker Jr., Dean of Public Health, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma Consultant Kathleen M. Rest, Assistant Professor, Occupational Health Program, Department of Family and Community Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts . . .

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SUBCOMMITTEE ON PHYSICIAN SHORTAGE Linda Rosenstock, (ChairJ, Director, Occupational Medicine, University of Washington, Seadle, Washington John A. Benson, cr., President, American Board of Interna Medicine, Portland, Oregon Joseph M. CannelIa, Corporate Medical Director, Mobil Oil Company, Princeton, New~lersey Linda Hawes Clever, (ex-officioJ, Chairman, Department of Occupational Health, Pacific Presbyterian Medical Center, San Francisco, California Jordan Cohen, Dean, School of Medicine, Health Science Center, State University of New York at Stony Brook, New York Mark R. lumen, Director, Yale New Haven Occupational Medical Program, Yale University School of Medicine, New Haven, Connecticut Frank Davidoff, Associate Executive Vice President, Education, American College of Physicians, Philadelphia, Pennsylvania Philip J. Landrigan, Ethel H. Wise Professor and Chairman of Community Medicine, Director, Environmental and Occupational Medicine, Mount Sinai Medical Center, New York, New York Richard C. Reynolds, Executive Vice President, Robert Wood Johnson Foundation, Princeton, New Jersey Consultant Kathleen M. Rest, Assistant Professor, Occupational Health Program, Department of Family and Community Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts lV

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institute of Medicine Staff Gary B. Ellis, Director, Division of Health Promotion anc' Disease Prevention James A. Frazier, Study Director James V. Warren, Study Director Emeritus Robyn Y. Nishimi, Senior Program Officer Rosena A. Ricks, Study Assistant Contributors Jack Berberich, Chief of Curriculum Development Branch, Division of Training and Manpower Development, National Institute of Occupational Safely and Health, Cincinnati, Ohio Eula gingham, Vice President and University Dean for Graduate Studies and Research, University of Cincinnati, Cincinnati, Ohio Joseph S. Castorina, Acting instructor, Occupational Medical Program, University of Washington Harborview Medical Center, Seance, Washington Terence R. Collins, Professor and Vice Chairman, Department of Preventive and Environmental Health, University of Kentucky, Lexington, Kentucky Anthony Cortese, Center for Environmental Management, Tufts University, Meciforcl, Massachusetts John E. Craighead, Professor and Chairman, Department of Pathology, University of Vermont, Burlington, Vermont John Edwards, Commanding Officer, Naval Environmental Health Center, Norfolk, Virginia Shirley Girouard, Program Officer, Robert Woocl Johnson Foundation, Princeton, New Jersey Harry Jonas, Director, Division of Undergraduate Medicine, American Medical Association, Chicago, Illinois

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Contributors (continued) Robert Lewis Kane, Dean, School of Public Health, University of Minnesota, Minneapolis, Minnesota Louis J. Kettle, Vice President, Division of Academic Affairs, Association of American Medical Colleges, Washington, D.C. Edwin M. Kilbourne, Chief of Health Studies Branch, Division of Environmental Hazards and Health Effects, Center for Environmental Health and Injury Control, Centers for Disease Control, Atlanta, Georgia Hugh McKinnon Office of Health Research, Environmental Protection Agency, Washington, D.C. Frank Mitchell, Chief Medical Officer, Agency for Toxic Substance and Disease Registry, Atlanta, Georgia Gregory Wagner, Director, Division of Respiratory Disease Studies, National Institute for Occupational Safely and Health, Morgantown, West Virginia Joan Wolle, Health Scientist Administrator, National Heart, Lung, and Blood Institute, Bethesda, Maryland Sponsors' Representatives Max Lum, Director, Division of Health Education, Agency for Toxic Substances and Disease Registry, Atlanta, Georgia David P. Rail, Director, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina J. Routt Reigart, Associate Professor of Pediatrics, Medical University of South Carolina, NIEHS Representative. Charleston, South Carolina Piston Seal, Medical Research Officer, Environmental Protection Agency, Research Triangle Park, \lorth Carolina vl