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Executive Summary TRODUCHON There is increasing concern that our highly sophisticated health care system is not well prepared to adclress problems in an important sector of medicine, those related to occupational and environmental factors. This concern arises in the face of the public's growing recognition and apprehension of adverse health effects associated with exposure to hazardous substances ire the home, the workplace, and the general environment. Only a small proportion of the more than half a million U.S. physicians are committed to occupational or environmental medicine. The American Board of Medical Specialties identifies only 1,064 physicians in the United States today who are board-certified in occupational medicine. Although about 4,500 physi- cians were members of the American Occupational Medical Association in 1986, only 400 physicians were members of the American Academy of Occupational Meclicine, an association of full-time practitioners of occupational medicine. These figures indicate that most individuals with occupational or environmental illnesses and injuries must obtain their medical care from physicians who are not specialists in either occupational or environmental medicine. For these reasons, the Institute of Medicine convened a committee to study how to foster the role of the primary care physician in environmental and occupational medicine. The physicians of particular concern to the committee include general internists, family physicians, osteopathic primary care physicians, emergency room physicians, and pediatricians. To the extent that other specialists, for example, cardiologists, gynecologists, and surgeons, provide general as well as specialty-specific health care, they, too, are part of the study's target audience. Some primary care physicians provide occupational medicine services through formal or informal relationships with companies, or, to a lesser extent, with labor unions. The small number of specialists in occupational and environmental

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medicine, although not the main target of this report, becomes important as consultants or educators. Although the report limits its discussion to physicians, many or its recommendations wade apply to other health care providers as well. The focus of this study is, therefore, on the physician of first contact who initially sees a person seeking medical advice. It is this physician who must be alert to a potential occupational or environmental cause for the problem and who must then call on the resources of the complex health care system for an accurate diagnosis and appropriate therapy. The question becomes: Is the physician's educational background and the support system of health care .' ~. . ~. , ~ r ~ . ~ . ~ ~ . . . . _ evade to tne pnys~c~an well attuned to this tasks The area of concern of this study on occupational and environmental medicine raised issues in definition. Some committee members favored use of , . . . . . . , ~ . . ~ the term health over medicine because the former emphasizes the broader preventive activities that are so important to the field. The term medicine was selectee! because it more accurately reflects the activities of the study's target audience. The borders of occupational medicine and environmental medicine are difficult to define. For the purposes of its study, the committee opted for a broad definition of occupational medicine and a more limited contemporary defini- tion of environmental medicine. In the broadest sense occupational medicine considers all aspects of the relationship between work and health, thus including the impact of disease on the ability to work. It is to a large degree concerned with the impact of work on the development of medical disorders. The definition and scope of environmental medicine are more complicated. In a literal sense, the environment is at least in part responsible for all diseases, except those determined solely by genetics. Thus, environmental medicine in that sense touches almost every aspect of medicine. The current popular conception of environmental disease is related to illness caused by external chemical or physical agents. The committee interpreted its charge from the Institute of Medicine to limit this definition further to exclude diseases caused by nicotine, alcohol, diet, or other life-style factors. This decision in no way denigrates the important contribution of these "environmental" factors to serious disease. In short, the committee's use ofthe term environmental medicine includes caring for individuals exposed to toxic substances in their homes and neighborhoods through such media as contaminated soil, water, and air. As a clinical specialty separate from occupational medicine, environmental medicine is in its infancy. There are no certifying examinations, mini-resiclen- cies, or prescribed courses of study. Moreover, with the exception of a small and controversial group known as clinical ecologists, few physicians, if any, devote their practices to environmental health problems. ANALOGS OF THE MOSLEM A substantial amount of illness, injury, and death is attnbutable to or affected by occupational and environmental conditions. Precise incidence and preva

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fence data are unavailable, ant] available estimates have been the focus of considerable debate. In a recent report, the Pane! on Occupational Safety and Health Statistics of the National Academy of Sciences concluded that even a measure as straightforward and important as annual occupational fatalities varied by a factor of 3 in 1984, from 3,740 estimated by the Bureau of Labor Statistics to 11,700 estimated by the National Safety Council. Frequencies and rates of occupational injury and illness are even more difficult to ascertain. There are several reasons for this difficulty: the long latency period between exposure and disease manifestation, multifactorial etiology of chronic disease, lack of recognition and diagnosis of occupational disease by physicians, and problems in underreporting. These factors become even more significant in the case of estimating environmentally related illness. There are virtually no reporting requirements, and the difficulties of recognition and diagnosis are further compounded by a paucity of defined clinical syndromes and some skepticism on the part of the medical community. PROBLEMS IN MEDICAL EDUCATION There is widespread agreement that, with few exceptions, physicians are inadequately trained in occupational and environmental medicine. Lacking a solid foundation in occupational ant! environmental medicine as well as in the related disciplines of epidemiology and toxicology, most primary care physicians are hard-pressed to keep up with developments in the field. Indeed, the general medical literature contains relatively little about occupational and environ- mental medicine. To ensure adequate undergraduate, graduate, and continuing medical education in occupational and environmental medicine, there must be suffi- cient faculty at each U.S. medical school, but the inadequate number of trained medical school facula in occupational and environmental medicine has been amply documented. Surveys by the Association of Teachers of Preventive Medicine indicated that only 59 percent of 102 U.S. medical schools responding to a questionnaire had any faculty in occupational medicine. Current federal extramural funding pertinent to environmental and occupa- tional health is obtained by medical school facula primarily from the National Institute of Environmental Health Sciences (NTEHS) ($31 million in fiscal year 1986), particularly in the area of toxicology. In comparison, the National Insti- tute for Occupational Safety and Health (NIOSH) awardecl only $3.8 million in fiscal year 1986 to medical schools from its grossly underfunded ($6.2 million) extramural budget. Medical school faculty also received $3.4 million in grants and cooperative agreements from the Environmental Protection Agency s $200 million fiscal year ~ 986 extramural research and clevelopment budget. Through its extramural research budget and mechanisms such as career development awards, the NIEHS has brought about a significant increase in medical school faculty number and teaching of toxicology. A similar approach is needed for other environmental health sciences and for occupational health. 3

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This lack of funding for faculty is the major cause of inadequate medical school teaching. A 1977-1978 survey of U.S. medical schools found that only 50 percent specifically taught occupational medicine as part of the required curriculum. By 1982-1983, the figure rose to 66 percent, but the number of required curriculum hours remained constant, 4 hours over 4 years. At the graduate level, a survey of 89 departments of internal medicine with identified divisions of general internal medicine found that 51 (57 percent) had no programs or clinics in occupational and environmental medicine. Only 20 programs (22 percent) offered clinical occupational medicine experience to residents: these courses were electives in almost all cases. The 1987 Association of American Medical Colleges survey of medical school graduates reported that only I.4 percent of all students took electives in occupational medicine (fewer than in any other field of medicine), and 50 percent felt that their instruction time in public health and community medicine was inadequate (60 percent felt that way about prevention). CONTSTRAINTS AFFECTING PRACTICING PHYSIC~NS ATTITUDES Another problem in the system relates to physicians' attitudes toward health promotion and disease prevention. As the scientific basis of clinical prevention is strengthened, prevention should become increasingly incorporated into routine medical practice. Yet the evidence suggests that physicians do a less than optimal job of delivering clinical preventive services. The overall barriers to the implementation of preventive seduces in the clinical setting also have an impact on the ability and willingness of the physician to deliver occupational and envi- ronmental health services. There are numerous constraints to the active partici- pation by the primary care physicians: Infrequent occurrence of occupational and environmental illnesses and . . . 1nJurles. Occupational and environmental events are often difficult and time . . consuming to c lagnose. Lack of information support available to the primary care practitioner. Limited relationship of practicing physicians with local health departments. Lack of payment for clinical preventive services. Entanglement with the workers' compensation system, often with payment delays, nonpayment for services, and additional paperwork. Lack of understanding of legal issues associated with occupational and environmental health. Ethically difficult situations arise frequently in the care of working patients, particularly when the physician is employed by the patient's employers. Fragmentation of responsibility among potentially helpful government agencies, particularly at the national level. 4

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GOATS FOR CLINICAL PRACTICE What extent of participation by the primary care physician can realistically be expected? The committee recognizes the broad responsibilities and multiple demands on these hardworking individuals, and it is unreasonable to think that most primary care physicians will become experts in ergonomics, toxicology, epidemiology, industrial hygiene, and the other disciplines central to the practice of occupational and environmental medicine. But it is equally unrea- sonable to prescribe educational and other interventions without stating a clear goal. This goal can be stated as follows: at a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals forfollo~up. In order to carry out this minimum standard of care, physicians must: Know some basic principles of occupational and environmental disease and understand the difficulties in precisely defining an individual patient's expo sures. Understand their responsibilities within the workers' compensation system. Know how to take an appropriate history in those clinical situations in which occupational or environmental disease are part of the differential diagnosis. Be sensitive to the ethical, social, and legal implications of the diagnosis of an intervention for occupational and environmental disease. Be alert to opportunities for the prevention of occupational and environ- mental illness in patients under their care. Call known or suspected hazards to the attention of public health agencies or other entities as indicated by the history and information obtained. PRINCIPAL RECOMMENDATIONS The recommendations derived from this study fall into two major categories: those designed to enhance the role of the present-day primary care physician in the occupational and environmental aspects of practice and those designed to enhance the training of future physicians for greater abilities and appreciation of this aspect of medicine. Underlying these are important general considera- tions that are critical to both endeavors. Recommendations to Foster the Role of Primary Care Physicians in Presently Patient Care Activities Disease and impairment problems attributable to environmental or occupa- tional exposures present unusual complexities in clinical medicine because the necessary expertise to assist the practitioner in documenting etiology as well as determining appropriate preventive activity is fragmented and often unknown to the primary care practitioner.

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Improved information sources are needed. The most practical way to assist the primary care practitioner to function effectively and knowledgeably when con- fronted with a patient suspected of having an occupational or environmental disease is to have a single-access point for all necessary clinically pertinent information. It should be designed so that a single telephone call satisfies the practitioner's informational needs. It could be based on an extension of the techniques used by the nation's poison control centers. The Institute of Medi- cine or other appropriate coalescing group, in cooperation with appropriate government agencies, should begin the efforts to achieve a meeting with the leaders of existing programs to initiate the establishment of such a project. The committee recommends an increase in the scope and availability of practice-oriented computer-based data handling systems for occupational and environmental medicine. The National Library of Medicine, which is already involvecl in such activities, should take the lead in future development of these systems. In addition, public health departments or other government agencies should make available to practicing physicians on a regular basis periodic reports of local disease incidence and exposure patterns for occupational and environ- meIltal illnesses to alert and remind physicians of current problems in the community. The Institute of Meclicine, or a similar body working with appropriate government agencies on a broad front, should bring to the attention of practicing physicians more information on occupational and environmental medicine by: Encouraging the publication of articles and reviews in the various journals dealing with clinical merlicine Encouraging special publications or bulletins, particularly from health departments, dealing with topics in occupational and environmental medicine. Encouraging the inclusion of occupational and environmental topics in programs of continuing medical eclucation. Stimulating the development of mechanisms to inform and guide physi- cians on the nonclinical means of assisting their patients, for example, by guiding a patient on how to obtain disability assistance or workers' compensa- tion. There is a striking shortage of clinically trained specialists in occupational and environmental medicine who can serve as consultants and educators. There are only about 1,000 active board-certif~ed specialists in occupational medicine in the United States, and the process of certification is difficult for candidates with a predominantly clinical background. Today, these few board-certifiecl special- ists in occupational medicine are for the most part employed by industry or academia and are not available to primary care physicians as clinical consultants. Additionally, only one-half of all medical schools have an identifiable faculty 6

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member in occupational medicine. Perhaps the shortage could be relieved by a new mechanism of certification of special clinical competence in the field, similar to that currently being undertaken in geriatrics. The Institute of Medi- cine should convene an ad hoc group to explore and initiate a means of correcting the national deficiency. Efforts should also be made to increase the number of primary care physicians with some special interest and training in the field of occupational and environmental medicine, without creating more full- fledged board-certified consultants. In addition to individual experts, primary care practitioners need access to referral centers that can provide comprehensive patient-specific occupational and environmental health services beyond those related to the diagnosis and treatment of disease. These should include services related to the evaluation of disability, facilitation of workers' compensation claims, rehabilitation and/or job retraining, and the provision of prevention-oriented resources. It is recom- mended that the Centers for Disease Control (CDC), through the NIOSH, convene a panel that would include representatives from the Social Security Ad- ministration, state workers' compensation programs, and other appropriate social service agencies to identify effective alternative means to meet this need such as through targeted support of labor education resource centers and com- prehensive occupational health clinics (those that provide nonclinical support services in addition to the basic clinical services). Consideration of the appropri- ate distribution and funding of the alternatives considered should be addressed. The CDC, through the Center for Environmental Health, should convene a similar panel to identify alternative means to deliver such services to those affected by hazards in the general environment. Due to the paucity of information about the practice patterns and activities of primary care physicians in today's changing medical scene with respect to occupational and environmental medicine, a broad and systematic survey of the needs and concerns of such physicians is recommended. Although it would be a major undertaking, a description of the evolving practices and problems of primary care physicians would be valuable in any future evaluation of the role of the primary care physician. Recommended Interventions in the Health Care System to Foster the Role of the Primary Care Physician The economic reward system for physicians dealing with the prevention and treatment of occupational and environmental problems should be improved. The current procedure-orientecl reimbursement system and the emphasis on efficiency of practice is antithetical to the desired emphasis on prevention. A new review and appropriate corrective actions regarding the provision of adequate compensation to inclivicluals suffering work or environmentally re- lated injuries and illnesses from either state or federal compensation systems are encouraged. /

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It is recommended that a second congressional review be undertaken to include specific consideration of the disincentives that the majority of workers' compensation programs present primary care practitioners with regard to their willingness to consider the role of work as the cause or a source of exacerbation of disease. Steps should be taken to clarify the physician's legal status when handling problems in this field of medicine. The appropriate federal agencies in associa- tion with the appropriate professional medical societies, local and state medical societies, and malpractice insurance carriers should develop resources that will provide primary care providers with basic information on their legal obligations. Steps should be taken to explore the ethical situation of physicians who deal with workers with occupational problems or those who work for businesses and industries. The appropriate professional medical societies should develop mocle] standards for contracts for use when a primary care practitioner agrees to provide routine medical services to businesses. Physicians should be informed regarding the unique aspects of the physician-patient relationship under these circumstances. Recommendations Re/a ted to the Education of Future Physicians Occupational and environmental medicine should be better represented in the medical school curriculum. In the eyes ofthe committee, this will not happen without changes in the academic status of occupational and environmental medicine and its representation in the medical school faculty. Occupational and environmental medicine should be a vital part of the traditional student clinical assignments. Because preventive medicine is usually not taught in the clinical years, it is necessary that departments of clinical medicine include occupational and environmental medicine as part of their third- and fourth-year teaching pro- grams. Noting that only 50 percent of medical schools indicate that they have at least one identifiable faculty member who is primarily concerned with occupational health, efforts should be made to provide all medical schools with at least one such faculty member. Mechanisms should be mobilized for the creation of such new academic faculty with academic credentials in teaching and research. For example, more career development awards similar to those that have been successful in other disciplines in medicine should be established. Mechanisms and resources for current facula to gain additional training in occupational and environmental medicine and the applicable basic sciences should also be established. In addition, a vigorous research program is required because too little research support is directed to this cause by the agencies that fund academic research. Government funding agencies should receive increases in monies for extramural funcling. Such an approach would enhance faculty numbers and help to achieve the desired goals of better teaching, to yield better informed physicians in the future, and to produce more specialists and faculty 8

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in the field as well as the much needed clinical consultants. Residency programs directed toward the production of general physicians in both internal medicine and family practice should be adjusted to provide more active clinical experience in occupational and environmental medicine. They should also contain instruction in such topics as epidemiology and risk assess ment. Additional opportunities for the pursuit of specialized residency and fellow- ship training in occupational and environmental medicine should be estate fished, and residents should be encouraged to participate in research activities. All educational efforts in occupational and environmental medicine should emphasize the physician's role in disease prevention and health promotion. GENERAL RECOMMENDATIONS Many of the proposals resulting from this study have a broad base in medical practice, medical education, and the functions of a number of government agencies. Assignment of responsibility for the pursuit of the recommendations to a single agency or group is often not appropriate. To ensure continued concern and activity, the committee recommends that the Institute of Medicine, in conjunction with representatives of government and private agencies, main- tain an active ongoing program to pursue these goals. In an effort to achieve a greater recognition of the important academic and clinical role of occupational and environmental medicine, steps should be taken to encourage greater representation of these areas in national and state board examinations required for certification and licensure. Occupational medicine is an established and recognized medical specialty. The steps recommended in this report should strengthen the position of occupational medicine as a vital component of clinical medicine. In contrast, environmental medicine has only a minimal structure of clinical specialists, professional societies, and specialtyjournals. Recognition as a clinical specialty area by the medical profession and the public is missing. The recommendations from this study, to be pursued by the Institute of Medicine and other agencies, should accelerate the evolution of environmental medicine into a viable, recognized, and accepted part of clinical medicine. 9

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Over and above the evil effects of a sedentary life, the affliction irz store for such workmen as a result of their craft is myopia, a well-known Affliction of the eyes which obliges orte to Ding objects closer and closer to the eyes in order to see them clearly; hence we may see nearly all such workers using spectacles when tthey are elaborating the details of their handiwork.