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CHAPTER 3 Goals and Interventions for Clinical Practice If one is concerned with fostering the role of the primary care physician in occupational and environmental medicine, one must ask to what end this should be done. It is unreasonable to think that most primary care physicians will become expert in ergonomics, toxicology, epidemiology, industrial hygiene, and other disciplines central to the practice of occupational and environmental medicine. But it is equally unreasonable to prescribe educational and other interventions without stating a clear goal. There must be a definition of success" that is, a vision of what a properly trained and adequately supported primary care physician should be expected to do. At a minimum, all primary care physicians should be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals for follow-tip. In order to carry out this minimum standard of care, physicians must: ,. Know some basic principles of occupational and environmental disease, including such concepts as latency and multifactorial etiology. Physicians should also understand the difficulties in precisely defining an individual patient's exposures and the concept of a threshoIcl dose. Understand their responsibilities within the workers' compensation system. Take an appropriate history in those clinical situations in which occupa- tional or environmental disease is part of the differential diagnosis. Be sensitive to the ethical, social, and legal implications of the diagnosis of and intervention for occupational and environmental disease. Be alert to the opportunities for the prevention of occupational and environmental 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. Primary care physicians with a special interest in occupational and environ- mental medicine, or whose practices include a number of patients with those 29

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illnesses, may reasonably be expecter] to do more than the minimum. With greater involvement, for example, primary care physicians may wish to diagnose and treat individual patients with occupational or environmental disease and refer them for preventive, legal, and other interventions. At a still higher level, physicians may elect to participate in the prevention and legal activities them- seIves. These greater levels of participation could not be expected of all primary care physicians, but the committee feels that at least the minimum amount outlined here should be expected of all of them PN ~ ~RVENTIONS As described in Chapter 2, primary care physician involvement in occupa- tional and environmental medicine is hampered in a number of ways. The health care delivery and public health systems do little to facilitate physicians' involvement; clinically useful information and accessible support systems are lacking; and economic, legal, and ethical matters sometimes present formidable constraints. Yet primary care physicians have a crucial role in efforts to address the growing concern with occupational and environmental diseases in the United States. Attempts to foster this role must necessarily address both the microenvironment of primary care office practice and the macroenvironment of the health care and public health delivery systems, including the influence of economics, law, ethics, patient demand, and professional societies. The committee examined both of these environments and recommencled a number of interventions that, if implemented, should both ease and promote the more active involvement of primary care physicians in occupational and environmental medicine. THE MICROEN~RONMENT OF PRIMARY CARE OmCE PRACTICE In making recommendations that wall affect the microenvironment of pri- mary care office practice, the committee made the following assumptions. First, primary care physicians care for individual patients; they tend to base their practice patterns on short-term outcomes and, to some extent, on recognized long-term risks. Most do not orient their practice to public health or research needs. Second, recommended interventions must foster activities that are realistic for busy primary care clinicians who may not consider occupational and environmental health to be any more important than many other areas of concern. In addition to all of the clinical aspects of their own specialty, primary care physicians must consider numerous other factors defined by social rather than strict biological criteria, such as family dynamics, human sexuality, alcohol- ism, and child abuse, of which occupational and environmental disease is simply one more. Indeed, the committee recognizes that providers who attempt to take a complete history in order to detect occupational and environmental illnesses, 30

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substance abuse, domestic violence, psychological depression, nutritional disor- ders, and the like will seldom get past the first patient. While clinicians may be willing to change their practice to include a quick screen for a documented problem, they will not be willing to become epidemiologists or pure public health practitioners. The third assumption is that activities that clinicians are encouraged to implement should be those demonstrated to be of significant short-term benefit to their patients. It is unrealistic to expect providers to devote much time to evaluating problems for which they see no useful intervention. Finally, primary care providers already engaged in the practice of occupational medicine through some link with a company or labor union have somewhat different roles, responsibilities, and needs in the diagnosis and management of occupational and environmental disease. Interventions clesigned to help these physicians may vale from those specifically designed to foster the role of the first-contact primary . . . care physician. In its deliberations, the committee was hampered by the paucity of informa- tion about the practice patterns of primary care physicians vis-a-vis occupational and environmental medicine. Although its meetings with small groups of primary care practitioners were helpful, the committee quickly recognized the need for a broad and systematic survey of primary care physicians' needs and concerns in this area. While it would be a major undertaking, a description of primary care physicians' current and evolving practice patterns in occupational and environmental health care would be extremely valuable for the implemen- tation of any of the recommendations made in this report. A survey could elicit physicians' perceptions of realistic and acceptable roles in occupational and environmental health care, as well as to help identify and further specify barriers to achieving these roles. Such a survey could serge as the basis of a conference, which would be convened to elaborate guidelines for primary care practice in the areas of occupational and environmental medicine. Such a consensus- building approach may enhance the credibility and acceptability of any guide- lines among community-based physicians. The committee recommends that one organization or agency, such as the Institute of Medicine (IOM) or the Centers for Disease Control (CDC), assume responsibility for conducting the survey and convening the conference. The subgroup of primary care physicians already engaged in some way in the practice of occupational arid environmental medicine should be identified, surveyed, and involved in a similar consensus-building effort to develop guide- lines relating to those areas most often addressed by these physicians, such as preemployment physical examinations, periodic screening, workers' compensa- tion, and injury care. Such a conference could also provide the groundwork for establishing the regional physician networks described later in this chapter. At the same time the committee understands the complexities of actually establish- ing such an arrangement. 31

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INFORMATION: WHAT IS NEEDED? Before primary care physicians can be expected to assume a more active role in occupational and environmental medicine, they will require readily available information. Some of these needs can be met by slight modifications to office practice. Most will require the sustained effort and involvement of outside resources. To care for working patients and individuals exposed to toxic agents in their environments, primary care physicians may require information on: Causative agents in occupational and environmental illnesses. Signs, symptoms, diagnosis, and treatment of occupational and environ- mental illnesses. Availability of consultants. Nonclinical and supportive interventions. Disease and exposure patterns within the community. The signs and symptoms associated with occupational and environmental diseases are seldom pathognQmonic, ancL thus make such illnesses sometimes ~iiff~cult to diagnose. When physicians need assistance, they may consult their office library or consult with their colleagues. Unfortunately, the number of primary care physicians who have expertise in occupational and environmental medicine is presently too small for convenient consultation. Ideally, each medi cal community should have at least one established physician who can be a source of this information on a regular basis. To encourage primary care physicians to assume such a role, mechanisms to support training and to provide ongoing assistance and encouragement must be developed. These could include routine communication via printed material and telephone contact with academic centers. Such active encouragement and support would likely expand sources of consultation for health maintenance organizations and large group practice associations, emergency rooms and urgent care centers, and hospitals. These efforts could also serve as the basis for the eventual development of regional networks of primary care physicians trained and interested in occupational and environmental medicine. These physicians would be readily available to provide information and first-line consultation. For example, an emergency room resident might call a local internist with known expertise in occupational and environmental medicine for help in dealing with a patient with a possible pesticide exposure. Even if primary care practitioners with special interest in occupational and environmental medicine could address the most immediate requests for local and informal consultation, a secondary need for more formal consultation would remain. The need for such a second-line consultation can be illustrated by a case in which a primary care practitioner sees a patient with chronic active hepatitis, rho history of alcohol abuse, and possible solvent exposure at work. In this situation, the primary care physician might consult an occupational medi- cine specialistjust as he or she would other clinical consultants. Local providers A_

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need to know where they can obtain consultations with such specialists in their area. Because these specialists are relatively few in number, their availability and accessibility to primary care physicians should be supported and encouraged through the efforts of state and local health departments and through the active involvement of professional occupational medicine organizations. Occupational and environmental illnesses and injuries may result in serious problems for the patient that are nonclinical in nature (Sullivan and Sokas, 1985~. For example, they may need help obtaining disability assistance and workers' compensation as well as help in dealing with employers and govern- ment agencies. Most physicians have no familiarity with public or private systems that offer assistance to patients with these types of problems. Experience has shown that physicians are not very effective in dealing with such diagnoses as child abuse, alcoholism, or the lack of appropriate home environments for chronically ill patients. Physicians are rarely adept at maneuvering through the maze of public and private assistance programs, nor are they often willing to help the patient through the system. Most, however, accept a role that includes ider~- tif~ring and referring the patient to the providers or programs they need. While they may be familiar with the types of agencies and social service programs that help patients deal with drug and alcohol abuse problems, they may be totally unaware of the types and availability of resources needed by patients with occupationally or environmentally related health problems. Indeed, in most areas, these resources may be totally lacking or so fragmented as to be virtually unavailable. There are, however, several types of organizations that could provide these types of nonclinical interventions. They include programs for occupational and environmental health within academic institutions and large clinical facilities. Local community organizations such as Coalitions for Occupational Safety and Health and nonprofit groups organized around specific environmental issues, volunteer organizations such as the American Lung Association and the Ameri- can Cancer Society, and, perhaps, existing social service agencies could also help in this capacity. Some of these organizations would require support to add staff to handle these types of patient-centered services. Once established, the availability of these resources must be publicized among local physicians. State and local health departments could help in this effort. It is important to remember that the resources continued use may be heavily influenced by the perceived success of the first few referrals. It is professionally embarrassing to refer a trusting patient for help, only to learn later that the patient received none. To be successful, organizations that provide the nonclinical support services must do more than trigger a range of possible actions; they must satisfy the patient and provide feedback to the referring , . pnyslclan. Even with the assistance of all the support systems described above, it may be difficult for newly interested primary care physicians to focus their attention on 33

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art approach to occupational and environmental diseases. These diseases en- compass a broad range of conditions, etiologies, and patterns. To enhance their practical interest and capabilities, primary care physicians need u~to{late and accurate descriptions of exposure and disease patterns in their immediate geographical area. While national statistics may be of some interest, information on local experience would be most helpful. Such information includes case reports, descriptions of exposure problems endemic to the industries or envi- ronment of the particular area, and statistical summaries of disease and expo- sure patterns in the area to help providers keep abreast of incidence and trends. INFORMATION: HOW TO PROVIDE IT? The foregoing discussion suggests that primary care physicians need several types of information to enhance their role in occupational and environmental medicine. This information can be provided in numerous ways, some of which have been briefly described. The format and manner of providing this informa- iion will greatly influence its utility to primary care physicians. This section recommends a variety of complemental modalities for providing timely and clinically useful information to primary care physicians. These include: A single-access information center. Enhanced practice-based resources. Enhanced clinical consultative resources. An expanded role for public health agencies. Continuing medical education. A Single-Access Information Center The committee recognizes a critical need for coordination of the wide range of information that may be needed to deal with patients' occupational and envi- ronmental health problems. The information needed extends beyond that usually available in the primary care physician's office and through routine consultation networks. The committee feels that a single-access center, perhaps established on a state or regional basis, will most effectively serve the occupa- tional and environmental medicine needs of primary care physicians. Available to all physicians by telephone, and itself a center of expertise in occupational and environmental medicine, the single-access center must be able to respond at many different levels, ranging from a simple telephone consultation on specific technical issues to requests for advice regarding available services for the comprehensive management of large-scale occupational and environmental problems. The single-access center should encompass expertise or offer access to a range of services that cover all aspects of patient care and exposure reduction. These include education, industrial hygiene, case reporting, diagnostic and treatment 34

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services, legal assistance, counseling, social services, and assistance in dealing with government agencies such as the Occupational Safety and Health Admini- stration (OSHA) and the Mine Health and Safety Administration. This assis- tance involves maintaining an unto date list of such services and knowing the types of responses that can be expected when these resources are used. For example, the center should know the policy of the local OSHA office regarding requests for inspections so that they can avoid suggesting an option that may be unavailable. If it is to be successful and widely accepted, the single-access center should be: Credible primary care physicians should know it by reputation and trust its competence. Capable the center should have a plan to handle growing demand. Clinically oriented-providers will be looking for specific clinical guidance, not research suggestions, statistics, or general discussions. ~ Accessible it must be consistently available on demancl or short notice. As described above, the s~ngle-access resource center would offer access to comprehensive clinical and nonclinical services through a consultation struc- ture, primarily utilizing other organizations to provide these services. The similarity between the single-access occupational and environmental health center and the poison control centers operated in many communities is obvious. Traditionally, poison control centers answer calls from the public about house- hold exposures and ingestions, particularly by children. In recent years, how- ever, many centers have expanded their mission. For example, the University of California at San Francisco, San Francisco General Hospital Center, has a much broader data base and receives many calls from industry, government agencies, and physicians es well as from the public. It operates 24 hours a day, 7 days a week. Similarly, the sophisticated center in Cincinnati (University of Cincinnati, Cincinnati General Hospital) also operates around the clock with a broad data base. It is widely used by physicians, and has a contract from the National Institute for Occupational Safety and Health (NIOSH) to train its own staff. The committee recommends that such systems be explored as models for the development of the single-access center described here. Like effective poison control centers, the single-access occupational and environmental health center needs an excellent communications system, a sophisticated and reliable data base, and well-trained communicators who interact well with health care provid ers. Practice-based Information Resources Primary care physicians are more likely to consult reference materials if they are accessible and easy to use. Several bibliographies of occupational and environmental medicine have been published (American Medical Association, 1981, 19~34~. Some could easily become part of an office library. These printed 35

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resources are handy, but they often become quickly out-of~ate. Computerized data bases are beginning to offer access to current and clinically useful informa- tion. Data Bases A medical decision support system has been defined as "any computer program designed to help health professionals make clinical decisions" (Shortlife, 1987~. Three types have been defined: bibliographic search systems, such as MEDLINE; factual data bases, such as TOXNET; and expert systems for supporting clinical decision making, such as DXplain (Barrett et al., 1987; Harris, 1987; Masys, 1987~. These systems are underutilized by practicing physicians, perhaps be- cause of the time required for information retrieval, lack of knowledge about their existence, unfamiliarity with computer use, unavailability of a microcom- puter and modem, and costs. Younger physicians tend to be more comfortable with computers, and many physicians are acquiring microcomputers for filing and record-keeping. As a result, more physicians will become computer literate, and will be better motivated to extend their use of the equipment to patient care. They may turn increasingly to the computer for assistance in diagnosis, treatment, and manage- ment. It is, therefore, imperative that the developing expert systems include, when appropriate, the dimensions of occupational and environmental medi- cine. Systems that relate clinical signs and symptoms to occupational and environmental exposures would be most useful to primer' care physicians in establishing a differential diagnosis. The committee recommends that the National Library of Medicine take the lead to: I. Develop and refine factual data bases relating to occupational and environ- mental meclicine. 2. Include the dimensions of occupational and environmental medicine in expert systems. 3. Disseminate information about the usefulness of data bases for diagnosis of occupational and environmental diseases. 4. Encourage the inclusion of lectures and workshops relating to the clinical value of microcomputer technology in continuing education programs. Record Systems Office-based record-keeping systems can help busy practitioners focus on oc- cupational and environmental health issues. Although several occupational and environmental history forms have been developed, they have not been widely used by primary care physicians Melton, 1980; American Lung Association of San Diego and Imperial Counties, 1983; Demers and Wall, 1983; Rest et al., 36

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1983a). Because of the breadth of their diagnostic challenges, it is unlikely that primary care physicians will use any detailed, highly focused, unidimensional record-keeping system. Rather, they should be encouraged to elicit information about the home, workplace, and community environment as part of the demo- graphic and social history. Questions on exposures should be included in any standardized history forms widely used by primary care physicians. When positive patient responses arouse suspicion, a more detailed history could follow. Practitioners who seek more detail or who want a way to organize a more comprehensive work and exposure history need validated and effective forms to collect this information. First, the committee recommends that the Centers for Disease Control (CDC) work with the appropriate professional societies to encourage practicing physi- cians to include basic questions relating to occupation, neighborhoocl, and home environments, including hobbies, in the social and demographic data base of each patient. These include questions on possible exposures and questions on the patient's perception of the relationship of these exposures to the symptoms or illness in question. Second, the Centers for Disease Control, with the assistance of the professional societies, should review, evaluate, and validate existing occupational and environmental history forms for use in primary care settings. Results could be reported in the appropriate medical journals and introduced in medical school courses. Finally, professional socie- ties should encourage the manufacturers of standardized patient record-kee' ing forms to include questions on occupational and environmental exposures and risk factors on their forms. Enhanced Clinical Consultative Resources In most subspecialty areas of medicine, the primary care physician has a reaclily available clinical consultant, such as a cardiologist or gastroenterologist, in his or her community. Due to the small number of clinical active specialists in occupational and environment medicine, this is not true in this field. The process of certification in this specialty has been macle more restrictive to those candidates with extensive experience in preventive medicine, so that the outlook for expandect numbers of clinically oriented specialists is not encourag- ing. The committee recommends that the Institute of Medicine (IOM) and appropriate professional agencies mobilize efforts to explore and initiate means of correcting the national deficiency of specialists in this field available as clinical consultants. In addition, similar needs exist in academia for clinically oriented faculty for the recommended expansion of clinical instruction in occupational and environmental medicine. Enhanced Consultative Services In addition to individual experts, there is a need for sophisticated comprehen- sive referral centers for patients needing occupational or environmental diagno 37

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sis and treatment of complex medical problems. The centers of excellence supported by the NIOSH in some way fit into this category. The center should be able to undertake the evaluation of disability, facilitate workers' compensa- tion claims, give guidance regarding rehabilitation orjob retraining, and other related activites. It is important that communication with the referring physician be maintained and a plan for the future management of the patient's problem be developecl. The committee recommends that the Centers for Disease Control (CDC) through the National Institute for Occupational Safety and Health (NIOSH) convene a group of representatives of other agencies to undertake the development of these consultative centers. Public Health Agency Information and Support Systems With few exceptions, public health agencies at all levels of government have been ineffective in giving primary care physicians the information they need in making occupational and environmental medicine a part of their routine. practice (Rosenstock and Landrigan, 1986~. Even physicians who provide occupational health services to companies and labor unions have often lacked information relevant to their local practice area. The committee recommends that local, state, and federal health agencies develop and disseminate informa- tion on community disease and exposure patterns based on their surveillance and enforcement efforts. Previous outreach efforts in occupational and environmental diseases have produced either exhaustive lists of all etiologies or summaries of the average national experience (Centers for Disease Control, 1983; Rutstein etal., 1983~. Since most communities have highly specific occupational en cl environmental profiles, it would be much more effective if providers recognized the occupa- tional and environmental diseases indigenous to their areas. To accomplish this, the CDC, the Environmental Protection Agency, and the National Institute of Environmental Health Sciences in cooperation with state health and environ- ment departments could regularly assemble a profile of disease and exposure patterns by community. These data could be distributed to all practicing physicians, along with information about the medical approach to these prom lems. Because the goal of this effort is to influence clinical primary care practice, the community surveillance report should emphasize case reports, experience patterns in local hospitals and clinics, and reports of the early detection and intervention efforts of the medical community. To enhance interest in the document, case reports could be attributed to the physicians involved in the case. Briefversions of the community profile could be incorporated into hospital intake forms and medical histories in the form of a checklist. By noting changes in the disease profile over time, the report could also have an evaluative function. At least one state health department (California Department of Health Services tCDHS] ~ has undertaken an educational outreach effort to enhance the ability of local primary care physicians to deal with hazardous waste site 38

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contamination (Neutra et al., 1987~. Evolving from their investigations and the concern of local citizens, the CDHS has developed an educational program to help practitioners deal with the growing issue of environmental contamination. Other states have alerted physicians about the threat of radon in high-risk communities. While outreach should not be limited to providing educational programs, such efforts are a commendable activity for state health departments. State public health agencies, with the help of the CDC, could further expand their role in fostering occupational and environmental medicine in primary care practice by establishing associations or networks for primary care physicians who provide formal occupational and environmental health services. As general physician awareness and use of occupational and environmental medical consul- tations grow, the demand for physicians with skills in occupational and environ- mental medicine will increase. States could help meet this demand by sponsor- ing and supporting a network of providers involved in different levels of occupational health care. To encourage primary care physician participation in the network, the state health agency couicl fashion several incentives. For example, on enrollment, the agency could add the physician's name to a list of specialists, which is then made available to individuals, employers, or unions who contact the health department for help. Enrollment could also make the physicians eligible for further state-supported training and, perhaps, establish them in part-time positions at local hospitals, in cooperation with local health authorities. The authorities could, in turn, designate the hospital for health department referrals. Continuing Medical Education Medical schools and scientific societies offer courses on a broad range of topics for which category ~ continuing medical education (CME) credits are given. Such accreditation has been established by national guidelines, first by the American Medical Association and then by the Liaison Committee on Continu- ing Medical Education, to preserve quality stanclards. These credits are required in some states for relicensure or for membership in state medical societies. Physicians have complete freedom to choose the category ~ credit courses of their choice, the criteria for which may include subject matter, location, costs, loss of income, expected gain in income, and vacation time. Those who offer category ~ CME courses to primary care providers face unusual obstacles to success. Attendees vary markedly in their basic scientific knowledge, clinical competence, and motivations for attending the course. Additionally, primary care physicians are selective in the types of CME courses they will attend. While they may be willing to spend 2 to 3 days to be brought up- to~ate in cardiology and rheumatology, they are less likely to spend a compa- rable amount of time in courses relating to hematology or pulmonary disease. These decisions relate to the nature of primary care practice. For these reasons, the committee recommends that information concerning environmental and 39

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occupational medicine be included within standarcl category ~ courses aimed at primary care practitioners, but the committee warns of the problems in develop ing successful separate courses devoted exclusively to occupational and environ- mental medicine for primary care practitioners unless warranted by a specific local issue. Even excellent continuing medical education conferences ant! authoritative consensus statements may not change physician behavior significantly. The need to develop and maintain an educational approach that provides a broad, repetitive, and prolonged exposure to appropriate messages is clear (Perry, 19871. Useful media include medical journals as well as nonprint sources, such as audio and video tapes and television and radio programming. Effective use of these media requires both the submission of more clinically relevant materials on occupational and environmental medicine and better research reports, as well as a willingness of the media to publish this material. Publication of articles by experienced and capable physicians in both society-sponsored and controlled circulation journals would be of value. If better and more research in the field could be attained, then good research reports should follow with more visibility in prestigious medical journals. Agency-sponsored publications based on the Morbidity and Mortality Weekly Report model could also be used to alert physicians to occupational and environmental concerns. Well-targeted physician bulletins arid newsletters developed and issued by Agency for Toxic Substance and Disease Registry (ATSDR) or local and state health departments would also assist primary care physicians in their continuing efforts to keep abreast of develop meets in occupational and environmental health. THE MACROENVIRONMENT OF MEDICAL PRACTICE System Interventions A variety of forces confront the physician who is involved in occupational and environmental medicine. As described earlier, many of these are economic, legal, and ethical in nature. While much can be done to enhance the microenvi- ronment of the primary care physician's office practice, an expanded role for these physicians will require changes in these external forces. The following sections suggest the types of changes that are required. Economic Interventions As describer! in Chapter 2, there are several powerful economic disincentives to primary care physician involvement in occupational and environmental medicine. These include aspects of the workers' compensation system and the reimbursement of cognitive and preventive services. The Occupational Safety and Health Act of 1970 created an expert panel to examine, evaluate, and report on workers' compensation its goals, its effective- ness in achieving the goals, and its remedies for the recognized problem of 40

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variation in coverage among states. The committee believes that a second congressional review of compensation to individuals suffering work-related injuries and illnesses is in order. The committee recommends that a second examination of state and federal workers' compensation systems be undertaken and include specific evaluation of the disincentives they present to primary care practitioners' willingness to consider the role of work in causing or exacerbating a patient's health problem. Consideration should be given to: I. Ways to prevent unreasonably long delays in payment for medical services (for example, by initial payment from third-party coverage until work related- ness is resolved). 2. Adequate payment for medical services (for example, by consideration of parity of payments with those for similar illnesses reimbursed under third-party systems). 3. Reimbursement for additional demands on physicians' time not usually associated with disease treatment (for example, payment for time preparing reports and preparing findings before workers' compensation commissions). 4. Reduction in unnecessary paperwork (for example, by developing under- standable and reasonable nationally standardized illness en cl injury reporting forms in a manner similar to the use of rational standards for the form of state birth and death certificates). Each workers' compensation program incorporates a statute of limitation for filing claims for occupational illness and injury. Physicians need to know about the various statutes of limitations and other rules in the workers' compensation system that provide and limit access to coverage. The committee recommends that the National Institute for Occupational Safety and Health (NIOSH), with the assistance of federal and state workers' compensation system representa- tives, develop educational materials for primary care physicians and patients about how the systems operate, including information on statutes of limitations, the general coverage available through these systems, and the process for obtaining reimbursement. Trends in third-party reimbursement favor enhanced rewards for investment in resources (for example, training), for cognitive services, and for preventive services. These and similar trends are likely to encourage primary care practi- tioners to prepare themselves arid keep abreast of occupational and environ- mental health concerns. Reimbursement could be transformed into an incen- tive rather than a disincentive in the system. The committee recommends that the Congress instruct groups that examine this issue, in particular the Physician Prospective Payment Commission, to consider these occupational and environ- mental health issues in developing recommendations for reform in the reim- bursement schemes. Similar recommendations should be conveyed to private . . . . groups examining sucn issues. 41

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f egal Interventions It is assumed that most primary care physicians want to limit their involvement with the legal system. This is entirely appropriate. For example, physicians can inform patients that they may have legal recourse in their efforts to obtain compensation without the physicians becoming directly involved themselves. The recommendations also assume, however, that primary care physicians have legal duties under common law to provide a reasonable standard of care, and that the standards in the area of occupational and environmental medicine are not fixed, but are and will continue to evolve. Primary care physicians need resources that will provide them with basic information on their legal obligations vis-a-v~s environmental and occupational medicine and with advice on how to better manage their interaction with the legal system. They also need information about the structure of the occupational and environmental health regulatory systems. This resource should include brief descriptions of the relevant agencies and laws, as well as the types of exposure and health effects data collected by and accessible through the agencies. These resources should be especially useful to primary care physicians engaged in occupational or environmental medicine. The committee recom- mends that appropriate federal agencies, such as the National Institute for Occupational Safety and Health (NIOSH) and the Agency for Toxic Substance and Disease Registry (ATSDR), work with professional societies, local and state medical societies, and malpractice insurance carriers to develop these resources ~ . . . tor primary care p Scans. Ethical Interventions Lack of awareness among primary care physicians about occupational and environmental health factors remains the largest obstacle to their successful recognition, prevention, and treatment (Rosenstock and Hagopian, 1987~. As with other areas of medicine, physicians have an ethical obligation to keep as informed as possible and to recognize when their knowledge or experience is ins~ffcient and consultation is needed. Primary care practitioners incur addi- tional ethical obligations when they provide occupational medical services to employers and unions. A varied of potential problems may emerge when physicians care for patients who work for an employer who hired the physician in the first place. As describer! earlier in this report, issues involving conficlenti- ality, physician autonomy relative to patient care, client expectations, and ability to act on recognized hazards may pose significant problems for physicians. The committee recommencis that the appropriate professional medical societies (for example, the American Occupational Medical Association, American Academy of Family Physicians, ant] American College of Physicians) develop mode! standards for primary care practitioners who agree to provide routine medical services for employees, such as preemployrnent or back-to-work examinations. These societies could also work together to develop a standard form that 42

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physicians should provide patients regarding the unique aspects of the physi- cian-patient relationship under the circumstances, to the degree that the relationship differs from that which is normally operative. The committee also recognizes the value of case histories that illustrate the range and complexity of the ethical issues that may arise when primary care practitioners agree to a role different from that which operates when the doctor-patient relationship is otherwise unencumbered. Such case histories should be developed and pub fished in journals most often read by primary care physicians. Professional Interventions The practicing physician's personal sense of accomplishment in dealing successfully with an occupational or environmental health problem encoun- tered in private practice can provide a significant incentive for further involve- ment in and sensitivity to these issues. This may arise from a single positive case experience in which a busy physician diagnoses an occupational problem (such as work-related allergy), contacts the employer to determine the nature of occupational exposure, arid brings resolution of the illness and the exposure hazard. The practitioner's interest and competency in occupational and environ- mental medicine also wall be influenced significantly by his or her contact with other physicians who deal with these aspects of medical practice. After comple- tion offormal training programs, the routine peer professional contacts include hospital and clinic staffs and committees, formal and informal interactions with colleagues, and membership in professional societies and associations. These spheres of influence can exert a strong and readily assimilated positive influence on physicians by recognizing and reinforcing their activities in occupational and environmental medicine. Primary care physicians belong to two types of professional organizations: those that include members from all specialties, which are generally geographi- cally defined and have broad educational, social, economic, and political objec- tives and functions (for example, the American Medical Association and state and county medical societies); and those groups defined by a specific specialty or field of medical practice. Examples of the latter include specialty colleges, local and national associations and societies such as the American Academy of Family Physicians, American College of Emergency Physicians, American Col- lege of Physicians, American College of Surgeons, and about 150 others. These organizations can be enlisted to help foster the role of their primary care physician members in occupational and environmental medicine. Indeed, several organizations have undertaken this type of activity in the past. The American Academy of Family Physicians and the Society of Teachers of Family Medicine worked with the American Occupational Medical Association to suggest guidelines and curricula for family physicians in occupational health. The American College of Physicians has issued a position paper on the internist's 43

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role in occupational medicine (American College of Physicians, 1984~. The committee recommends that these organizations institute or reinvigorate their occupational and environmental health committees, and that these committees actively pursue programs to instruct and assist their primary care physician members in the relevance of occupational and environmental medicine to their clinical practice. These committees should also encourage the inclusion of articles relating to occupational and environmental medicine in their organiza- tions' professional journals. Organizations made up of occupational and environmental medicine special- ists, such as the American Occupational Medical Association, can also be encouraged to interact with primary care physicians and to promote the participation of their members in activities designed for primary care physicians. For example, they can invite and encourage primary care physicians to attend their local meetings, participate in educational programs at local hospitals and clinics, make rosters of specialty consultant resources available to primary care physicians, and prepare articles and case studies for publication injournals read by primary care physicians. Patient Demand Interventions Publicity about numerous health risk factors in the print and broadcast media has stimulated a sharp increase in public awareness of illness prevention measures. As a result, we have seen a significant reduction in cigarette smoking and, to some degree, the consumption of distilled alcoholic beverages. Concern about cholesterol and its relationship to heart disease has altered the diets of millions of Americans. The federal antihypertension program has been a resounding success. These and other health issues receive continued reinforce- ment in the public's mind as new data are reported in the news on a daily basis. The general interest in health promotion, together with specific concern about such matters as stress and fitness, has fostered the rise of new growth industries related to health enhancement. Exercise equipment and stress management programs are but two examples. Providers of such equipment and services can be expected to continue to expand their trade with additional promotion which, in turn, keeps disease prevention in the public eye. The media has also called attention to numerous occupational and environ- mental health risks. Local newspapers frequently carry stories about asbestos and pesticide and other chemical exposures, as well as accounts of environ- mental contamination and hazardous waste. One effect of this heightened awareness will likely be felt by primary care physicians whose patients are concerned about these risks and about disease prevention in general. Efforts that stimulate an increasingly informed public to raise such questions in their contacts with physicians are important. Worker and community right-to-know laws will increase the likelihood that physicians will be asked about specific chemical and physical hazards. 44

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Federal agencies responsible for occupational and environmental health should give higher priority to proaci~vely developing accurate information about issues for dissemination to the media, with the goal of informing physi- cians indirectly through their patients. Information should be disseminated both in the form of tip sheets that outline issues and contact points for the press and through more in~epth features that are suitable for use by newspapers. Patients can also influence the economic problems associated with poor reimbursement for preventive services. They may be important advocates for broadening coverage through union-management negotiations during collec- tive bargaining. Both union and nonunion workers can lobby their state legislatures for laws that mandate such coverage. 4:

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Punters themselves {elf me that after they have applied themselves to their task the whole day long and have left the shop they, fancy even at night that those lefters which are pranted on their imagination keep moving to arad fro before their eyes for many hours, until their images are blotted out fly the forms of other objects.