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CHAPTER 5 Summary of Principal Recommendations The recommendations derived from this study fall into two major categories. First, there are those designed to foster the role of the presentably primary care physicians in the occupational and environmental medical aspects of their practice. Second, there are those designed to enhance the training of fixture physicians for greater appreciation and abilities in this aspect of medicine. Underlying these are important general considerations that are critical to both endeavors. ner. RECOMMENDATIONS TO FOSTER THE ROLE OF PRIMARY CARE PHYSICIANS IN PRESENT-DAY PATIENT cAREAcTr~TIEs Disease and impairment problems attributable to environmental or occupa tuna exposures present unusual complexities in clinical medicine. For ex- ample, the necessary expertise to assist the practitioner in documenting the etiology is often fragmented and may be unknown to the primary care practitio The committee feels that as a minimum, all primary care physicians shouicl be able to identify possible occupationally or environmentally induced conditions and make the appropriate referrals forfollozmnp. 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. Understand their responsibilities within the workers' compensation system. Take an appropriate history in those clinical situations in which occupa- tional or environmental diseases are 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 opportunities for the prevention of occupational and environ- mental illness in patients under their care. 63

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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 illnesses, may reasonably be expected to do more than the minimum. The committee feels that at least the minimum amount outlined here should be expected of all. To foster such enhanced activity, the committee recommends several steps. ~ . Improved information sourcesfor the physician are needed. The most practical way to assist the primary care practitioner to function effectively and knowledgeably when confronted with a patient suspected of having an occupational or environ- mental disease is to have a single~ccess point for necessary clinically pertinent information. This single-access point should become the central source through which all appropriate clinical ant} nonclinical services available to the practitio- ner coup be elicited. The development of such an access point for health care providers needs to be designed so that a single telephone call will satisfy the practitioners rued to access the full range of information necessary to address the patient's problem. It might be an extension of the techniques used in the nation's poison control centers and other information systems currently in operation. It is important to note that attempts to achieve this goal will demonstrate that in many situations the desired data are not as fable from any source. The Institute of Medicine, or some other appropriate coalescing group, in cooperation with the appropriate government agencies, shouIc3 initiate the efforts to achieve a meeting with the leaders of existing related programs and other information services to initiate the establishment of such a project. The committee recommends an increase in the scope and availability of practice-based data hand~ngsystems for occupanonal~and environmental medicine. This includes printed resources, computer-based data and bibliographic sys- tems, and so-called expert systems of data handling in the field. The committee suggests that the National LibraIy of Medicine, which is already involved in such activity, take the lead in future clevelopment. The committee recommends that public health departments or other govern- ment agencies regularly make available to practicing physicians periodic reports of local disease incidence and enclosure pattems for occupational and environmental illness. This would alert and remind the physician of current problems in the community. The Institute of Medicine, working with the appropriate government agen- cies on a broad front, should bring greater dissemination of information on occupa- tional and environmental medicine to the attention of the practicing physician such as: Encourage the publication of articles and reviews in the various journals dealing with general clinical medicine. 64

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Encourage special publications or bulletins, particularly from health departments, dealing with topics in occupational and environmental medicine. Encourage the inclusion of occupational and environmental medicine topics in programs of continuing meclical education. The committee feels that courses on occupational and environmental medicine may have limited appeal, but the inclusion of occupational and environmental medical topics in more general courses such as cardiology and rheumatology would reach more physi- cians. Stimulate the development of mechanisms to inform and guide physicians on the nonclinical means of assisting their patients. For example, this could include directing a patient on how to obtain disability assistance or workers' compensation. 2. Improved availability of clinical consultation services are needed.There is a striking shortage of clinically trained specialists in occupational and environmental medicine to serge as consultants en c! educators. There are only about 1,000 active board- certified specialists in occupational medicine in the entire country, and the process of certification is difficult for candidates with a predominantly clinical background. Today, these small numbers of board-certified specialists in occu- pational medicine are mostly 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 member in occupa- tional medicine. Perhaps the shortage could be relieved by a new certification mechanism of special clinical competence in the field, similar to that currently being undertaken in the area of geriatrics. The Institute of Medicine should convene an ad hoc group to explore and initiate means of correcting the national deficiency. Efforts shouIc! also be made to increase the number of primary care physicians with some special interest and training in the fields of occupational and environmental medicine, short of full-fledgec} board-certified consultants. In addition to indiviclual experts, there is a need for primary care practitioners to have available referral centers that can provide comprehensive patient-specific occupational ant} environmental health sentences other than those related to the diagnosis and treatment of disease. These include the identification and coor- dination of services related to the evaluation of disability, facilitation of workers' compensation claims, rehabilitation or job retraining, and the provision of prevention~riented resources. It is recommended that the Centers for Disease Control (CDC), through the National Institute for Occupational Safety and Health (NIOSH), convene a pane! that would include representatives from the Social Security Administration, state workers' compensation programs, and other appropriate social service agencies. This pane} would identify effective alternative means to meet this need, such as through targeted support of labor education resource centers and comprehensive occupational health clinics (those which provide nonclinical support services in addition to the basic clinical 65

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services). Consideration of the appropriate distribution and funding of the alternatives should be addressed. The CDC, through the Center for Environ- mental Health (CEH), should convene a similar pane} to identify alternative means to deliver such services to those affected by hazards in the general environment. 3. Recommended interventions in the health care system to foster the role of the primary care physician are needed. The economic reward system should be improved for the physician dealing with the prevention and treatment of occupational and environmental illnesses. The current procedure-oriented reimbursement system and the emphasis on efficiency of practice is antithetical to the desired emphasis on prevention. A new review and appropriate corrective actions should be encouraged in the troublesome aspects of the workers' compensation system. The Occupa- tional Safety and Health Act of 1970 included a specific charge that an expert pane] be created to examine, evaluate, and report on workers' compensation, its goals, its effectiveness in achieving the goals, and remedies for the recognized problems in variation in coverage between states. There is general recognition that it is timely and necessary for a general review of the provision by either state or federal compensation systems of adequate compensation to individuals suffering work or environmentally related injuries and illnesses. Such a review should be undertaken to include specific consideration of the disincentives that the majority of workers' compensation programs present primary care practitio- ners with regard to their willingness to consider the role of work as the cause or a source of exacerbation of disease. Consideration should be given specifically to ways to prevent unreasonably long delays in payment for medical services, adequate payment for medical services, reimbursement for additional demands on physicians' time, and reduction in unnecessary paperwork. Steps should be taken to clarify the physician's legal status when handling problems in this field of medicine. The legal obligations of primary care practitioners, when addressing diseases caused by or contributed to by environ- mental or occupational risk factors, are complex and not well understood. It is recommended that appropriate federal agencies, in association with appropri- ate professional meclical societies, local and state medical societies, and malprac- tice insurance carriers, provide primary care providers with basic information on their legal obligations. Steps should be taken to explore the ethical situation of physicians dealing with workers with occupational health problems or practicing as a representative of industry. Primary care practitioners assume ethical obligations when contract- ing with business concerns to provide selected patient evaluation services. It is recommended that the appropriate professional medical societies develop mode] stanciards for contracts for use when a primary care practitioner agrees to provide routine medical seances (for example, preemployment or back-to 66

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work examinations) to businesses. Physicians should be informed regarding the unique aspects of the physician-patient relationship under these circumstances. 4. A study to determine the needs and concerns of primary care physicians. Unfortu- nately, in formulating these recommendations our limited knowledge about the changing needs and practices of the primary care physician becomes apparent. Due to the paucity of information about the practice patterns and activities of primary care physicians in today's 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 contemporary practices and problems of primary care physicians would be most valuable. Such a study could be carried out by the Institute of Medicine and appropriate professional societies with the assistance of concerned government agencies. The survey of these physicians should determine the extent of their present and past practice of occupational and environmental medicine, including preemployment physicals, workplace and union clinics, and so on; barriers associated with the practice of occupa- tional and environmental medicine; their ideas about acceptable and ideal roles of primary care physicians in occupational and environmental medicine; and their needs for continuing medical education in occupational and environ- mental medicine. It should be part of a broader national concern for the future role of the primary care physician. RECOMMENDATIONS RELATED TO THE EDUCATION OF FUTURE PHYSIC~TS I. There should be a better representation of occupational and environmental medicine in the medical school curriculum. In the eyes of the committee, this will not happen without changes in the academic status of occupational and environ- mental medicine and their representation on the medical school faculty by appropriately trained facula members. If occupational and environmental medicine are to be properly represented in the clinical years of medical education, adjustments must be made in many schools to make it part of the mainstream of clinical medicine. It should be a vital part of the traditional clinical assignments of students. As preventive medicine is usually taught during the years that students learn clinical medicine, it is necessary that departments of clinical medicine include occupational and environmental medicine as part of their third- and fourth-year teaching pro- grams. By whatever sponsorship, students should have active clinical experience in occupational and environmental medicine. Noting that only 50 percent of medical schools have an iclentifiable faculty member listed as being primarily concerned with occupational medicine, efforts should be made to enable all medical schools to have at least one such faculty member. Mechanisms should be mobilized for the creation of such new academic 67

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faculty with academic credentials in teaching and research. For example, the establishment of more career development awards similar to those that have been successful in other disciplines in medicine should be undertaken in this fielcl. In addition, the committee recommends the establishment of mechanisms and resources for current faculty to gain additional training in occupational and environmental medicine arid the applicable basic sciences. 2. If occupational and environmental medicine are to prosper in academia, a vigorous research program is required. Review of the support of occupational and environmental medical research in the academic environment as described in this report indicates that too little research support is directed to this cause by the agencies invc>Ived. Government funding agencies should receive increases in monies for extramural funding. This should be aimed at allowing the National Institute of Environmental Health Sciences (NIEHS) to broaden its mandate to support environmental health sciences, in addition to toxicology, and providing the NIOSH and other pertinent CDC components (Agency for Toxic Substance and Disease Registry, CEH) with a genuine extramural research program capable of enlisting American medical schools in the CDC's environmental and occupational health mission. Such an approach would enhance faculty numbers and help achieve the desired goals of better teaching to yield a better-informed physician in the future and produce more specialists and faculty in the field and the much needed clinical consultants across the country. 3. 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 shouIcl also contain instruction in topics such as epidemiology and risk assessment. Additional opportunities for the pursuit of specialized residency and fellow- ship training in occupational and environmental medicine should be estate fished, with encouragement 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. GENES RECOMMENDATIONS 1. 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 ongoing program to pursue these goals in the years to come. 2. In an effort to achieve a greater recognition of the important academic and clinical roles of occupational and environmental medicine, steps should be 68

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taken to encourage greater representation of these areas in the examinations of the various national and state boards for certification and licensure. This should include family medicine, internal medicine, pediatrics, and obstetrics/gynecol- ogy. 3. Finally, the committee hopes that pursuit of these various recommenda- tions would have an enhancing effect on the place of occupational and environ- mental medicine in the world of health care. Occupational medicine is a long establisher} and recognized medical specialty. Since its roots have traditionally been in prevention, it is often not viewed as a mainstream component of clinical medicine, not only in practice but in medical education and research as well. Occupational medicine, for example, may not be represented in a medical student's clinical assignments. The steps recom- mended in this report should strengthen the position of occupational medicine as a vital component of clinical medicine. In contrast, environmental medicine does not have a structure of clinical specialists, professional societies, specialty journals, and so on. Recognition as a clinical specialty area by medicine 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 subspecialty of medicine. The committee sees merit in these subjects being taught and evolving clinically together rather than being strictly separated. ~9

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~ - By= I rim 1 0 sum up: Meal in the learned professions should bend themselves to the pursuit of wisdom, but [et them set some limit to their praiseworthy tulrelage, nor should they become so entirely absorbed in cultivating the mired as to neglect the care of the body; [et them preserve the equipoise of their team, so that mind and body, in trusty comradeship, like guest and host, may serve one another and not take turns in wearing each other dowel.