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CHASER 6 Concluding Remarks The committee has addressed its task with enthusiasm and concludes this report with optimism not for a quick fix but for a number of steps that can enhance the occupational and environmental aspects of medical practice. Fostering the role of the primary care physician in the practice of occupa- tional and environmental medicine, especially its preventive aspects, is not a simple matter. Too often, it has been dismissed with a call for more education and more attention to occupational history taking. Taken together, it was assumed that these steps would solve the problem. Not so. Attaining optimal clinical practice by the primary care physician in this field of medicine is fraught with multiple problems. These include deficiencies in the primary care physician's basic perception of occupational and environmental medicine, their limited place in general clinical practice, and their low visibility in the medical education process. The data base for the clinical practice of occupational and environmental medicine is frequently available only with difficulty to the practicing physician. it iS often in the hands of government agencies, is much fragmented between and within occupation and environment, and is not organized for an easy interface with the practicing physician. The type of practice activity emerging from occupational and environmental medicine demands much time, currently at such a premium in primary care practice, with a low financial reward. These factors compound the increasingly recognized physician dissatisfaction with the sharp discrepancy in personal reward between the non-procedure-oriented primary care practice and the procedure-oriented specialty. Despite these constraints, the committee feels that there is a mosaic of feasible steps that could enhance this area of medical practice considerably, with greater satisfaction for physician and patient alike. Complete resolution of some of the issues would require a more sweeping overhaul of the structure of medical practice. One is tempted to base an appeal for more attention to occupational and environmental medicine by the primary care physician on numbers, yet calcu 71

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rations yield paradoxical results. With the entire population of this country exposed in one way or another to environmental hazards and as many as 70 percent of the adults having the aciditional exposure of a workplace, one might expect that the incidence of morbidity would be great. Unfortunately, as noted in this report, accurate figures are not available. On the other hand, when calculated with the best available figures in the context of a primary care physician's daily practice, only number of encounters might be expected each month, unless one includes an extensive list of possible exposures for almost all patients. These figures clo not attract the attention of the busy physician who encounters so many more frequent and demanding problems. The average primary care physician does not consider occupational and environmental medicine part of the mainstream of clinical medicine. Occupa- tional medicine is considered a rather arcane subspecialty of practice, largely in the hands of physicians trained in preventive medicine. In medical education, it is not a highly visible part of the student's clinical experience or a resident physician's rotational program through clinical specialties. Environmental medicine appears even more nebulous to the physician, with no visible structure as a medical specialty, no specialists, and few textbooks orjournals. A physician's information about environmental medicine comes mainly from the news media or from patients, frequently in the form of frustrating questions for which there are no readily available answers. Compared with cardiology or hematology, it is difficult to find a clinical consultant in the community who can deal with occupational or environmental problems. The need for readily available clinical consultants is impressive to the committee. The committee recognizes the limiter] presence of occupational and environ- mental medicine in most medical school educational programs. The startlingly few identifiable curricular hours continue, despite vigorous efforts over the past decade by the National Institute of Occupational Safety and Health, the Health Resources and Services Administration, and others that have had only minimal impact. A major reason is the lack of faculty with expertise in occupational or environmental medicine or sufficient peer recognition to successfully compete for time in a medical school curriculum committee. On the other hand, one must consider the plight of medical education. Medical schools are being called on to devote more time to a wide variety of clinically oriented topics including geriatrics, nutrition, cancer, and the medical humanities. At the same time, there has been an almost explosive increase in knowledge of the scientific base of medicine to be taught in the preclinical years. As a result, the medical curriculum has become overstuffed to a degree that appalls educators and that may deter students from entering medicine as a career. In his presidential address at the annual meeting of the Association of American Medical Colleges in 1987, Dr. Edward StemmIer, Dean of the University of Pennsylvania School of Medicine, inclicated that the trade-off decision between the amount of basic science and new clinical material to include in the curriculum is a major question 72

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facing medical educators. While the fate of occupational and environmental medicine in medical education is entwined in these considerations, without trained faculty there will be no opportunity to teach the subject. Many recommendations of this report relate to the practical realities of office practice; some call for basic and systemic changes. In many areas of medical practice, there is the strong and widespread belief that physicians should spend more time and effort on disease prevention and health promotion. Although highly desirable in concept, the practice patterns of today's physicians must emphasize efficiency and cost containment, leaving little time for preventive efforts. The procedure-based reimbursement system gives little economic re- ward for time spent on prevention. These are issues of great importance in medicine today, and they will not likely be addressed in the field of occupational and environmental medicine alone. Finally, meetings with several groups of practicing physicians have empha- sized the reality of a rapidly changing scene of primary care. Complex new factors of regulation and economics are molding the way physicians practice medicine. The physicians still wish, however, to provide their patients with the best that medical science has to offer. The committee is optimistic that the steps recommended here will aid in achieving that goal. ~3