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CHAPTER 2 The Cause for Concern An Analysis of the Problem INCIDENCE OF OCCUPATIONAL ADD EN~RONMENTTA! DISEASE A substantial amount of illness, injury, ant! death is attributable to or affected by occupational and environmental conditions. Precise incidence and preva- lence data are unavailable, and estimates have been the focus of considerable debate. In a recent report by the National Research Council (1987), the Panel on Occupational Safety and Health Statistics of the National Academy of Sciences (NAS) conclucled that even a measure as straightforward and impor- tant as annual occupational fatalities varied by a factor of 3 in 1984 from 3,740 estimated by the Bureau of Labor Statistics (BES) to 11,700 estimated by the National Safety Council. Frequencies and rates of occupational injury and illness are even more difficult to ascertain. Through itS annual survey, the BES estimates that 5.3 million work-related injuries occurred in 1984, at a rate of 7.S per 100 full-time workers (Bureau of Labor Statistics, 1986~. Agriculture, mining, construction, and manufacturing had the highest injury rates ~ 1.0 per 100 full-time workers. The service sector had a considerably lower rate of 6.0 injuries per 100 full-time workers. Occupational illness data are more problematic. In 1984, 124,800 new cases of occupational disease severe reported by the BES, but because occupa- tional illnesses can take a long time to develop, this figure is almost certainly an underestimate. The inadequacy of the data has long been recognized, and a concern about substantial underreporting exists. The previously mentioned NAS pane! found no straightforward estimates of the extent of underreporting of occupational injuries in the BES annual survey data. In 1984, a congressional committee reported that "no reliable national estimates [of occupational disease] exist today" (U.S. Congress, House, 1984~. The same committee concluded that statistical information on occupational illness remained grossly inadequate in 1986. Estimating the incidence of occupational illness is difficult for several reasons: the lord latency period between exposure and disease manifestation, the multifactorial etiology of chronic disease, the lack of recognition en cl diagnosis 15

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of occupational disease by physicians, and the underreporting problems noted above. These same factors become 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 th medical community. More precise estimates are needed to target and evaluate public health and primary prevention activities, as well as to address social concerns about compen- sation costs, the burden on the medical care system, workers' quality of life, and effects on employees. To help focus attention on the occupational health issues, the National Institute for Occupational Safer and Health (NTOSH) developed a list of the 10 leading work-related diseases and injuries based on disease prevalence and exposure estimates, as well as on their amenability to prevennon~riented activities (Centers for Disease Control, 19831. These are given in Table 2-~. Once again, it is important to remember that work-related is a tw~pronged concept. It relates to diseases caused or exacerbated by work and to diseases that affect one's ability to work. In addition, the NIOSH has published morbidity, mortality, and exposure estimates in the Morbidity and Mortality Weekly Rope The data are acknowledged to be irregular and incomplete, yet they provide a helpful starting point. EVIDENCE OF NEED AND LE:SS THAN OPTIMAL PHYSIC~N PARTICIPATION Nearly 104 million men and women make up the U.S. work force. Approxi- mately 70 percent work in plants without any medical services. Only a small proportion of the more than half a million U.S. physicians indicate a commit- ment to occupational or environmental medicine. The American Board of Medical Specialties identifies only 1,064 physicians in the United States today who are board-certifiec! 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 Amencan Academy of Occupational Medicine, an association that requires its members to be full-time practitioners of occupational medicine. As a clinical specialty separate from occupational medicine, environmental medicine is in its infancy. Physicians primarily identified as occupational medi- cine specialists are often referred patients with environmentally induced ctisor- clers. There are no certifying examinations, mini-residencies, or prescribed courses of study in environmental medicine. 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. Taken together, these figures suggest that most individuals with occupational or environmental illness ant! injury obtain their medical care from physicians who are not specialists in either occupational or environmental medicine. Primary care physicians become involved in occupational injury and disease 16

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TABLE 2-1 The 10 Leading Work-Related Diseases and Injuries in the United States, 1982 1. Occupaiional lung diseases: asbetosis, byssinosis, silicosis, coal workers' pneumoconiosis, lung cancer, occupational asthma 2. Musculoskeletal injuries: disorders of the back, trunk, upper extremity, neck, lower extremity; traumatically induced Rayrlaud's phenomenon 3. Occupaiional cancers (other than lurk: leukemia, mesothelioma; cancers of the bladder, nose, and liver 4. Amputations, fractures, eye loss, lacerations, traumatic deaths 5. Cardiovascular diseases: hypertension, coronary artery disease, acute myocardial . ~ . ntarctlon 6. Disorders of reproduction: infertility, spontaneous abortion, teratogenesis 7. Neurotoxic disorders: peripheral neuropathy, toxic encephalitis, psychoses, extreme personality changes (exposure-related) 8. Noise-induced loss of hearing 9. Dermatologic conditions: dermatoses, burns (scaldings), chemical burns, contusions (abrasions) 10. Psychologic disorders: neuroses, personality disorders, alcoholism, drug dependency NOTE: The conditions listed under each category are to be viewed as selected examples, not comprehensive definitions of the category. SOURCE: Centers for Disease Control. 1983. Leading work-related diseases and injuries UnitedStates:Mor~'dityandMortalityWeeklyR~ort32~21:2~26,32;32~14~:189-191. in two ways. The first is when the physician's patient has an injury, illness, or risk factor that may be work-related. The second is when the physician has a formal or informal relationship with a company to provide medical services, such as preemployrnent physical examinations ano Injury care. Each case involves different assumptions about levels of service and obligation. Neither case ensures that the physician will have adequate training. It is not known to what extent these physicians recognize and diagnose occupational and environmental illnesses, but it is assumed by many to be less than optimal, given the difficulties described previously and the paucity of training described in the following section. it is widely held that the occupational and environmental histories are the keys to uncovering occupational and environmental diseases Melton, 1980; Goldman and Peters, 1981~. In one study of an academic family practice center, only 24 percent of the 624 patient charts had any mention of occupation (or unemployment) whatsoever. Only 2 percent of the charts had any information on exposure, duration of present employ- ment, and past occupations (Demers and Wall, 19834. In its 1990 objectives for the nation, the U.S. Department of Health anal Human Services (DHHS, 19SOa) identified the clinical setting as an important site for achieving its goals to prevent occupational illness ancE injury. One objective stated that, "by 1990, at least 70 percent of primary health care providers should routinely elicit occupational health exposures as part of patient history and should know how to interpret the information to patients in an understandable manner." In its 1986 midcourse review, the DHHS (1936) con- ceded that the objective was unlikely to be met. The present study goes beyond 1

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the issue of history taking to address the broader question of the role of the physician of first contact in occupational and environmental medicine. The primary care physician confronted by unfamiliar clinical problems of an occupational and environmental nature lacks a ready source of information and, if necessary, clinical consultation. These are hard to come by. Standard textbooks of medicine and the more widely react medical journal provide lithe organized information about this field of medicine. At best, a brief list of references may be available, but this is of limited value to the busy physician. In the committee's meetings with practicing primary care physicians this lack of information was stressed as a major problem. As one put it, physicians need something similar to a 911 telephone number to get information quickly. Information on toxic substances and their effects is available from a number of government agencies, but the sources are a confusing array not well organized for easy access by the average physician. Furthermore, even with the best efforts, much needed information for practice does not exist. If information alone was not enough for the clinical problem, then the physician might desire a consultation or wish to refer the panent to a referral center. There are problems in obtaining a consultant or finding a referral center. In other fields of medicine, such as cardiology or gasl:roenterology, a steadily available clinical consultant is usually available to the general physician. Not so in occupational anti environment medicine. Of the approximately 1,000 active board-certified occupational physicians, most are employed in industry and academia and are not readily available as clinical consultants. In environmental medicine there are even greater limitations. The lack of availability of clinical consultants in this fielcl of medicine is serious in the eyes of the committee. The number of certified physicians in occupational medicine (a subspecialty of We American Board of Preventive Medicine) has remained relatively CQ~S.tant-~D recent years. The committee is apprehensive that new requirements that stress extensive training in preventive medicine may limit even more the number of clinically oriented specialists available as consonants to the primary care physi- cian. As will be discussed later., the small supply of clinically oriented specialists is also important in academia. CHANGING SCENE OF MEDICAL CARE The preceding discussion of who does and does not provide occupational and environmental medical care suggests a relatively static view of American medi- cine. Nothing could be further from the truth. The health care system in the United States is undergoing a sweeping transformation (Starr, 1982; Wenk- enwerder ant] Ball, 1988) that affects even aspect of the delivery of curative and preventive services. When a system is being disturbed, it is ripe for change. What follows is a brief examination of three factors that may provide the seeds for changing the delivery of occupational and environmental health care services: the increasing concern for cost containment, the oversupply of physicians, and 18

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the aging of the population. These three trends are particularly relevant to increasing primary care physicians' involvement in the delivery of preventive ser'vices, of which occupational and environmental medicine are a part (Nut- ting, 1986~. As medical care costs rise, new organizational forms of managed care will expand their influence. Depending on where they are located, these new organizations may see occupational and environmental medicine as potentially lucrative "product lines." This reasoning could result in an expansion of the delivery of those services. At the same time, institutionalized quality assurance programs may lead to the development of more "medicine by protocol." In such a system, adding occupational and environmental etiologies to the differential diagnosis is theoretically as simple as drawing one more box in the algorithm. Adclitionally, there may be an incentive for providers of managed health care to identify problems as work-related to the extent that these can be reimbursed outside the capitation system, namely, through workers' compensation. On the other hand, the rise of managed systems may work against further delivery of occupational and environmental health services. Cost containment quickly gives rise to concern about provider productivity, which can easily translate into less time per patient encounter. This response can interfere with the often lengthy history taking that is required when all disease etiologies must be considered. Also, fear of alienating large corporate purchasers of care may encourage these prepaid plans to avoid the preventive aspects of occupational and environmental medicine particularly if they involve following up known or suspected hazards- and instead concentrate on quick turnaround services like preemployment examinations or evaluation of on-thejob injuries. Physician oversupply (U.S. Department of Health and Human Services, 1980b) might enhance the delivery of occupational and environmental health services as physicians seek to develop unique niches. On the other hand, some forces affecting the financing of health care may work against these efforts. Physicians will have to increase their efficiency, thereby forcing them to limit the amount of uncompensated time spent discovering the toxic etiology of a patient's symptom or consulting with the Occupational Safety and Health Ad- ministration. Further, they are likely to intensify their competition for the health care dollars of the most affluent members of society, those most likely to retain generous insurance coverage. This population is generally somewhat removed from occupational and environmental hazards. In addition, the spectre of more and more doctors chasing fewer and fewer health care dollars would tend to increase a bias toward high-technology medicine and away from relatively low- cost preventive services. Finally, the emergence of geriatrics as a central concern in medical practice may work for or against the wider delivery of occupational and environmental health services. Patients will be older, and fewer may be employed. On the other hand, the aging of the population may create pressures for retaining the elderly on the payroll, enhancing their ability to work, and recognizing occupational and environmental diseases early in life to preserve the functional indepen 19

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dence of the elderly. Indeed, prevention of disability in elders has already become part of public policy (U.S. Department of Health and Human Services, 1979~. There is little doubt that these and other factors of the rapidly evolving health care system will affect the delivery of occupational and environmental health care services. The opportunity for change is there; the direction is yet uncertain, but it is amenable to influence. There are numerous reasons why primary care physician involvement in occupational and environmental medicine has been less than desired. Some are related to a lack of training and competence in the area; others flow directly from physicians' attitudes regarding health promotion and disease prevention. The economic, legal, and ethical aspects of providing occupational and environ- mental health services also provide some powerful disincentives. These issues are examined in the following sections. INADEQUATE EDUCATION There is widespread agreement that, with few exceptions, physicians are inadequately trained in occupational and environmental medicine. A 1977-1978 survey of U.S. medical schools found that only 50 percent of them 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 (Levy, 19851. 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 (sullen, 19871. Only 20 programs (22 percent) offered clinical occupational medicine experience to residents, and in almost all cases these were electives. Among the reasons for the lack of occupational and environmental health training are an absence of clinical role models, a limited research presence, and the perennial problem of an overcrowded curriculum in which all departments vie for limited time. To be sure, occupational diseases and the impact of work and the environment on health may be addressed piecemeal in many different courses and electives, but they are not usually emphasized. As a result, with certain well-known exceptions, students are not prone to think of possible occupational or environmental etiologies. Medical students themselves appreciate the inadequacy of their training in the field. A survey of medical school graduates done by the Association of American Medical Colleges reported that only 1.4 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) (Associa- tion of American Medical Colleges, 1987~. Lacking a solid foundation in occupational and environmental medicine as well as in the related disciplines of epidemiology and toxicology, most primary ~0

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care physicians are harcI-pressed to keep up with developments in the field. Indeed, the general medical literature contains relatively little about occupa- tional and environmental medicine (see the abstract of the paper by Lerman and Goldstein in Appendix A tLerman and Goldstein, 1987] ~ . It is little wonder that the primary care physician's knowledge base in this field is limited. LACK OF MEDICAL SCHOOL FACULTY To assure adequate undergraduate, graduate, and continuing medical edu- cation in occupational and environmental medicine, there must be sufficient faculty at each U.S. medical school. The best curriculum is of no value if there is no one capable of teaching it. The inadequate number of trained medical school faculty in occupational and environmental medicine has been amply documented. Surveys by the Association of Teachers of Preventive Medicine indicate that only 59 percent of the 102 U.S. medical schools have any faculty in occupational medicine (Association of Teachers of Preventive Medicine, 1986~. The paucity of faculty in occupational medicine is due to weakness in both demand and supply. As described later (see Chapter 4), the lack of demand reflects the reluctance of deans and department chairs to hire full-time occupa- tional medicine faculty because of the almost complete nonavailability of federal competitive research funding. Such support, if available, would permit the classic pattern of medical research that is a primaryjustification for the hiring of full-time teaching faculty at a medical school. The lack of supply is evidenced by the difficulty experienced by those medical schools attempting to hire faculty in occupational medicine. It would require more than ~ O percent of the total number of active board-certifiecl physicians in occupational medicine to supplyjust one faculty member for each U.S. meclical school. With rare exceptions, active medical school programs in occupational medi- cine have been the 14 programs that are part of the National Institute for Occu- pational Safety and Health Educational Resource Center (ERC) network. This very important program was begun by the NIOSH in part to develop profession- als in all areas of occupational health. While achieving some success, the ERC program has been in almost constant budgetary crisis, including many years in which the initial NIOSH budget request has had a zero support level. The resultant survival atmosphere has not been conducive to the development of strong sustainable programs that can serve as the source of faculty for U.S. medical schools. The number of ERCrsupported medical school programs that could survive a totalwithdrawal of NIOSH support has been a matter offrequent speculation. Without another source of funding, such as a well-financed extramural grants program, relatively few ERCs would likely survive. Vigorous support of the ERC program is necessary to provide additional faculty for training future primary care practitioners in occupational medicine. One exception to the dearth of faculty in occupational and environmental medicine is in the field of toxicology. Sustained extramural funding of toxico 21

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logic research by the National Institute of Environmental Health Sciences, as well as by Career Development Awards, has inevitably led to the development of medical school facultywith interest arid expertise in teaching this subject. There are full-time faculty members from 79 U.S. medical schools who are members of the Society of Toxicology (Society of Toxicology, 1987), an organization that generally requires a modest amount of peer-reviewed publications for member- ship. PRACTICING PHYSICIANS APTITUDES TOWARD HEALTH PROMOTION AND DISEASE PREVENTION 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 (Relman, 1982~. Yet the evidence suggests that physi- cians do a less than optimal job of delivering clinical preventive services (Gemson and Elinson, 1986~. When surveyed, they cite a variety of constraints, including inadequate reimbursement, lack of expert consensus on the types and frequency of services to be provided, minimal patient demand, structure of the medical care encounter, and lack of training in patient education skills (Wechsler et al., 1983; OrIeans et al., 1985; Nutting, 1986; Henry et al., 1937~. These overall barriers to the implementation of preventive services in the clinical setting also affect the ability and willingness of the physician to deliver occupa- tional and environmental health services. In addition, occupational and envi- ronmental medicine bring their own special constraints to the arena of clinical practice PROBLEMS IN PRACTICE While physicians are always motivated to improve patient care, several prac- tical problems may surface as they attempt to integrate occupational and environmental medicine into their practice. Fow-Frequen~y Events The primary care physician sees a variety of diseases that approximate the patterns of illness in the community as a whole (McWhinney, 1981~. These include, for the most part, acute, self-limited illnesses; prevalent chronic diseases (for example, hypertension, diabetes, arthritis); and behavioral problems. The clinical adage "when you hear hoofbeats, don't think of zebras" is part of the primary care physician's everyday mental construct. Events that appear to occur infrequently will be considered infrequently. Is occupationally induced disease an uncommon event in primal care? If one simply considers an estimate of incident cases and divides it by the number of family physicians and internists, one may conclude that occupational disease is a low-frequency event in primary care. This view ignores prevalence and the 22

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importance of risk factor recognition, and fails to take the comprehensive view of work relatedness described earlier. Occupational and environmental risk factors are not low in frequency, nor are health problems that affect one's ability to work. For example, recognition of occupational noise exposure as a risk factor can prevent an incident case of noise-induced hearing loss. Likewise, determi- nation of the appropriate time to return to work following recovery from an acute myocardial infarction may be of central importance to patient well-being. Environmental risks also appear frequently in primary care. Counseling a parent whose child plays in a lead-contaminated environment can prevent an incident case of childhood lead poisoning. Time Constraints Diagnosing occupational and environmental illnesses is not easy because few have specific, pathognomonic findings (Imbue, 1975~. When confronted with a possible occupational or environmental etiology, family physicians may need to consult textbooks that are not likely found in an office library or conduct a literature search (Michaels et al., 1983~. Such activities can be both time- consuming and expensive and are somewhat outside the realm of routine patient care. The physician needs ready resources and a systematic approach. Lack of Support When primary care physicians encounter or suspect an occupational or environmental health problem, they may need information on exposures, informal or formal medical consultation, and advice about the nonclinical aspects of caring for the patient. Such support may be totally lacking in a given area, or it may be so fragmented as to make it virtually unavailable to the busy practitioner. Physicians may be at a loss as to where to look, who to call, and how to proceed. Limited Relationship with Health Departments While physicians may turn to local, state, and federal health departments for help with infectious diseases and food-borne illnesses, they may be totally unaware or skeptical of the health departments' roles in other areas of medicine and health. Primary care clinicians have little experience with health depart- ments and are unlikely to consider them part of their normal support system. ECONOMIC ISSUES The economics of diagnosing and treating occupationally and environmen- tally mediated diseases may affect the primary care physician's willingness to get involved. A number of incentives and disincentives can be identified. Impact of Eves of Reimbursement In general, when a physician identifies a medical condition as work-related, the patient's health insurance does not pay for trea~anent. Insteacl, benefits are ~3

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paid under the applicable state workers' compensation statute, but only if the worker decides to file a claim. Such action may place the patient in an adversarial relation to the employer and may require the panent to consult an attorney. So- called first-party insurance differs from workers' compensation in benefits covered and options available for cost containment. These differences can affect the quantity of medical services demanded and the level of payment for specific procedures. Most state workers' compensation systems pay all "usual and reasonable" charges for medical care in the course of processing a claim. Few have the rigid cost-containment procedures often found in first-party coverage. In this context, workers' compensation payments may be higher than first-party payments for identical procedures. Some states, however, have strict cost controls and pay all charges based on a fixed fee schedule. In such states, the workers' compensation payment is generally lower than the first-party payment. Moreover, balance billing billing the patient for charges above the amount allowed by the workers' compensation carrier is generally not permitted. This limitation can further reduce the physician's reimbursement for treating a work- related condition to below that of treating a nonoccupational disorder. Thus, when cost controls are tighter under workers' compensation than under first-party insurance, fee-for-service providers face a loss in income when treating workers for occupational illnesses or injuries. Prepaid plans, on the other hand, may have a cost-shifting incentive to label conditions as occupation- ally related. Payment Delays and Nonpayment Medical care providers who report an illness as occupational may discover that no insurance payments are forthcoming at all. The first-party insurer does not cover work-related conditions. The workers' compensation claim may be con- tested, especially in the case of occupational disease. Workers' compensation insurers and self-insured employers contest 60 to 80 percent of all long-latency occupational disease claims, denying that the conditions are work-related (Barth and Hunt, 1980~. In most states, contested workers' compensation claims are not paid by either insurer until this issue is resolved. Typically, this can take 1 to 3 years. The deejay can create significant cash flow problems for physicians. Additionally, the escalation of a claim to the level of litigation may be a further economic cost to the physician. If, however, the legal dispute involves the tort system and not the workers' compensation system, the physician will likely be well compensated for his or her time. Paperwork The paperwork burden is generally much greater for workers' compensation than for first-party claims. Forms must be completed and letters written to explain when the patient may return to work, the nature and extent of work restrictions, the extent of permanent disability attributable to workplace expo 24

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sure, the extent of preexisting disability, and the rationale for the assessment of work relatedness. This additional effort is uncompensated and constitutes another barrier. Nonpayment for Prevention Lack of reimbursement for clinical preventive services is an important barrier to their delivery (Gemson and Elinson, 1986) . Some important medical services related to occupational and environmental health are preventive in nature- notably, surveillance of individuals by means of examinations, laboratory tests, or radiographs. Insofar as private insurance resists paying for preventive seances, it will resist paying for these services as well. GAL ISSUES The level of annoyance, time lost from other clinical activities, and inconven- ience engendered by paperwork or by the gatekeeper function are small compared with the costs of becoming entangled in litigation over work related- ness, readiness to return to the job, or the extent of permanent impairment or disability. In some occupational disease claims, the treating physician may be summoned to testify or depose about these issues. The doctor-patient relai~on- ship is always at risk when the doctor testifies in court. A single such experience may greatly reduce the physician's interest in determining the work relatedness of similar illnesses among other patients in the future. On the other hand, physicians may enjoy the challenge of the scientific inquiry involved in testifying. They may further enjoy the generous financial remuneration that often flows from tort action. The legal system creates another powerful incentive for physicians to recognize occupational and environmental etiologies of disease the spectre of malprac- tice liability. Physicians have some statutorily determined legal obligations in the areas of occupational and environmental health. These generally relate to the discovery, reporting, and treatment of occupational disease. Other duties are derived from the common law, which defines the standards for physician accountability. For a person to prevail in a malpractice action against a physician, it must be proved that the physician owed the plaintiff a legal dub, the duty was breached, and harm was done as a result of that breach. Physicians are expected to act reasonably with regard to the circumstances of the case. Reasonable actions encompass but are not limited to the standards of practice established by their peers. Further, the duties imposed on a primary care physician acting in the role of a patient's individual physician may differ from those that arise when the care is related to the patient's employment for example, preemployment examina- tions or examinations conducted as part of a workers' compensation claim. In the context of primary care, a central question is whether the physician has a duty to take occupational and environmental histories. Another issue is

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whether there is a duty to discover an occupational risk factor or disease or to realize that an illness is related to employment or to exposures from other sources. One might expect a greater duty to be imposed on physicians who practice in an industrial area or in an environmentally polluted community. Physicians who function as part-time company doctors may be construed as claiming a special competence in occupational medicine. If so, the physician could be held to a higher standard. ETHICAL ISSUES There is growing recognition of the ethical dimensions of occupational and environmental medicine (Rosenstock and Hagopian, 1987~. Ethically difficult situations arise frequently when physicians care for working patients, especially when the physician works for a company, even OI1 a part-time basis. The problem of divided loyalties occurs when the physician has both a patient and a client (the company), each with conflicting demands and expectations. In this context, employers may expect physicians to function as agents of social control, making determinations about when, where, and if an individual will work. Patients, on the other hanci, may expect physicians to protect their interests and function as advocates when problems arise at work. While it may seem inherently clear to primary care physicians that their primary obligation is to their patient, regard- less of payment source, this perception is challenged when medical services are provided through agreements with employers. The issue of confidentiality is routinely encountered when physicians care for working patients, especially in the context of preemployment physical examina- tions and periodic medical screening programs. The former are done for job placement purposes, while the latter are done to assess an individual's current health status or future risk and his or her relationship to job performance or possible financial expenditures for the company. It is not surprising that employers desire information on the results of such examinations and tests. Workers, on the other hand, usually consider the personal and medical informa- tion they share with physicians to be confidential. Client companies do have a right to know about an individual's ability to work and whether specific restnc- tions are necessary. They also have a need to know about health problems caused or aggravated by exposures at work in order to take effective preventive measures. Patients have a right to privacy when it comes to personal and diagnostic information. Primary care physicians must decide where to draw the line. A more subtle but equally important issue relates to the extent to which physicians are ethically responsible for reporting or otherwise acting on known or suspected hazards. Informing a patient about his or her condition and the risks involved with that condition is an integral part of patient care. Failure to go beyond this may place the patient and his or her coworkers at risk of immediate or future harm. But taking action is not a simple matter. Most primary care 26

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physicians are unsure of how to proceed in these situations. Indeed, their actions are notwithout risk to themselves and their future interaction with the company and to the patient, who may suffer discrimination or job loss as a result. FRAGMENTED AGENCYRESPONSIBILITY The responsibility for occupational and environmental health in the United States is spread among a number of federal organizations. Some of these organizations are primarily regulatory, some are primarily aimed at developing the scientific and technical information base for public health decisions, and some are a mixture of both. In the Department of Health and Human Services, these include three components of the Centers for Disease Control (the National Institute for Occupational Safety and Health, the Agency for Toxic Substance and Disease Registry, and the Center for Environmental Health), the National Institute for Environmental Health Sciences, and the National Center for Toxicology Research. The Environmental Protection Agency is an independ- ent federal agency that has both research and regulatory responsibilities. The Occupational Safety and Health Administration is a regulatory agency located in the Department of Labor. Pertinent research is also performed at a variety of other organizations within the National Institutes of Health, including the National Cancer Institute. This multiplicity of agencies reflects certain aspects of our federal administrative system and the wishes of Congress. Efforts have been made by a variety of interagency groups, such as the Task Force on Environmental Causes of Cancer and Heart and Lung Disease and the Committee to Coordinate Environmental and Related Programs. However, any substantive activity must involve the bureaucracies arid the cumbersome clear- ance procedures of each of the participating agencies. Many ofthe issues discussed in this report do notfal1 clearlywithin the purview of any single federal agency, but rather are of interest to all agencies. Physician education and activities to enhance the effective functioning of primary care practitioners in occupational and environmental medicine are examples of such issues. These issues are not of the highest priority at any one agency, but are of some interest to many agencies. This results in the unfortunate but common practice of each budget-smrved agency claiming that there is no need to support a program because some other agency is responsible. The inability to clearly and cleanly assign responsibilities greatly complicates the implementation of many recommendations made by this committee. Thus, a wide spectrum of factors exist that may limit the optimal participation of primary care physicians in occupational and environmental factors in the patient care that they deliver. 2;

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n' }A 1~ - ~ ~_. ~ In, ~ Pitiable therefore is the lot of these workers, for since they very often have no other home than a small boat, when they fall ill they are obliged to go into a hospital, where it is impossible to enter on the precise and proper treatment for them unless the doctor knows clearly in what sort of occupation the patient is ertgaged.