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APPENDIX A
Abstracts of Commissioned Papers
THE ROLE OF THE PRIMARY CARE PHYSICIAN IN b:GALASPECTS OF
OCCUPATIONAL HEALTH
Nicholas A. Ashford
This paper has two purposes. The first is to describe the nature and extent of
the legal obligations of the primary care physician that are related to occupational
health. The second is to discuss the opportunities for the primary care physician
to assist both the worker and his or her employer in preventing or minimizing
exposure to occupational health hazards and to assist the worker in obtaining
compensation for occupational disease.
The first purpose is primarily related to the discovery, reporting, and treat-
ment of occupational disease. In a small minority of states, there is a statutory
duty imposed upon all physicians to report an occupational disease to the public
health authorities. There is no similar federal statutory requirement. There are
adclitional duties, recognized in the common law (i.e., law developed through
court cases), arising from medical practice. Failure to properly execute these
duties could leave the physician liable in a negligence suit for malpractice. The
duties imposed on a primary care physician acting as an individual's personal
physician may be different from duties that arise when the medical practice is
related to an individual's employment, (i.e., preemployment physical examina-
iior~s, periodic physical examinations, or examinations undertaken for the
purposes of medical removal, workers' compensation, or a third party lawsuit in
tort). Duties to discover and report occupational disease are discussed at length
in this paper. Referral to other specialists is a key element in contributing to the
discharge of both the legal and ethical responsibilities of the primary care
. . .
pnyslclan.
The second purpose of this paper focuses more on prevention and compen-
sation. Federal and state laws empower and enable the indiviclual worker (and/
or his or her union) to utilize legal machinery to reduce the incidence and
severity of occupational disease. This includes legislation for the control of toxic
substances, right-to-know laws, antidiscrimination laws, and the worker's right to
refuse hazardous work. Through a variety of laws, manufacturers and employers
are directed to disclose or provide access to information regarding toxic
substance exposure and the subsequent health effects to workers, to unions in
their capacity as worker representatives, and to government agencies charged
with the protection of the public health. The underlying rationale for these
directives is the assumption that this transfer of information will prompt activity
that will improve worker health.
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The primal care physician can play a vital role that goes beyond diagnosis and
the direct provision of medical care. It is important for the physician to
understand both the legal obligations of the employer and the employer's
permissible uses of medical data. A number of federal agencies such as the
Occupational Safety and Health Administration, the National Institute for Oc-
cupational Safety and Health, the Environmental Protection Agency, and the
National Labor Relations Board offer means and mechanisms to prevent
occupational disease. These are discussed at length. It is hoped that this paper
will provide guidance to the primary care physician who cares for people who
work.
SURVEILLANCE OF OCCUPATIONAL DISEASE: STRATEGIES FOR IMPROVING
PH\SICWN RECOGNITION AND REPORTING
Edward F. Baker
Modern systems for the surveillance of disease and injury have three compo-
nents: data collection, data analysis, and a capacity for response. In the recent
past, surveillance of occupational disease and injury has focused primarily on
developing techniques for data gathering and data analysis, with relatively little
attention given to response. Future efforts at surveillance of occupational
disease and injury should be motivated by attempts to collect data in a way that
will lead directly to action~oriented intervention for the prevention of these
.
conditions.
Unfortunately, in the minds of many public health professionals, surveillance
systems are viewed as passive, imprecise, and ponderous systems designed to
collect information of uncertain Utili~. To achieve a broader involvement of
occupational health professionals in the surveillance of occupational disorders,
systems must be developed that are intrinsically active and precise and that allow
for a rapid response to the emerging trends of illness and injury.
In accomplishing such a transition, the ultimate goal is to develop a surveil-
lance system that has the capacity to respond to changes in workplace hazards
and to provide data that direct the efforts of health professionals to intervene in
the workplace. Furthermore, the usefulness of the surveillance system should be
immediately apparent to occupational health professionals who contribute data
to the system. Unfortunately, many surveillance systems fail through an inability
to demonstrate that data are used to direct intervention efforts. At present, the
National Institute for Occupational Safety and Health (NIOSH) is involved in an
intense effort to improve existing surveillance systems, to develop new am
preaches to identify occupational illness, and to monitor trends of disease and
injury. To be successful, such development must derive from a cooperative effort
of all those who will ultimately be responsible for surveillance programs.
Although many states have laws that require health providers to report cases
of occupational illness and injury, most do not maintain a comprehensive system
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that actively identifies and targets potential sources of case reports and then
responds to such reports. To address this need, NIOSH proposes to establish a
Sentinel Event Notification System for Occupational Risk (SENSOR) that will
utilize targeted sources of sentinel providers to recognize and report selected
occupational disorders to a state su~veilance center in the state health depart-
ment.
INCENTIVES TO DIAGNOSE, TREAT, AND REPORT OCCUPATIONALAND
ENVIRONME:NTAL DISEASE
Leslie I. Boden
The extent of the involvement of primary care physicians in the control of
occupational diseases depends on the incentives they face and the costs they may
incur. Incentives are increases in payments for medical services. Costs include
reductions in income, payment delays, extra paperwork, impacts on the physi-
cian-patient relationship of the treating physician's role in determining work
restrictions, and involvement in legal disputes.
Impact on Physician Income. When cost controls are tighter under workers'
compensation, fee-for-service providers face a loss in income when treating
workers for occupational injuries or illnesses. Prepaid plans have an incentive to
identify claims as occupational, although this incentive may have a small impact
on provider behavior. Of these impacts, the most important is probably the very
low workers' compensation fee scale. Unlike the typical medical insurance
policy, workers' compensation has no deductibles or coinsurance. As a conse-
quence, where workers have a free choice of physician, workers' compensation
increases the demand for medical senTices. However, this is probably not an
. .
Important Incentive.
Payment Delays. Medical care providers who report an illness as occupational
may receive no payments from any source if the claim is contested. This may
result in payment delays of one to three years after the initial diagnosis.
Paperw - . Most workers' compensation jurisdictions require physicians to
spend more time on paperwork than is required by first~party insurers.
The Gatekeeper Function. When treating workers with occupational diseases,
physicians may find themselves in the middle of a dispute between the worker
and the employer, disrupting the physician-patient relationship and making
diagnosis and treatment more clifficult.
Direct Involvement in Legal Disputes. In some occupational disease claims, the
treating physician may be summoned to testify about these issues, an occurrence
that many find anxiety provoking or humiliating. This experience often inter-
feres with the physician-patient relationship.
Recommendations.
I. Workers' compensation fee schedules should not pay considerably less for
medical services than first-party medical insurance.
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2. When liability for a workers' compensation claim is contested, first-party
insurers should be requires! to pay for covered services and be reimbursed by the
insurer or self-insured employer if the claim is eventually paid.
3. Only the minimum necessary paperwork should be required of treating
physicians. The required forms should be as easy as possible to fill out.
4. When there are disputes between worker and employer, the treating
physicians should not play the role of gatekeeper.
5. To the extent feasible, primary care physicians should be insulated from the
workers' compensation litigation process.
THE CHALLENGE OF TEACHING OCCUPATIONAL AND EN~RONMENTAL MEDICINE IN
INTERNAL MEDICINE RESIDENCIES
Mark R Cullen
A simple survey of residencies demonstrates that the teaching of occupational
and environmental medicine (OEM) to medical residents is inadequate; both
faculty and elective opportunities are scant, based on data from the Division of
General Medicine chiefs. Previous approaches to the problem have emphasized
strategies for directing moreattention to the field. In this paper, which examines
the problem in the context of imminent changes in the way residents are trained,
the focus is directed more specifically at the content.
The basis for this emphasis on content is the recognition that large societal
and medical economic forces will, in and of themselves, increase the attention
paid to OEM. There are five discernible forces pushing in this direction: patient
demands for OEM services are growing, and consumer power is at an all-time
high in a competitive health market; regulatory and legal pressures are leacling
employers to provide more OEM service; business is cutting back on in-house
medical departments; health care financing dictates that hospitals more aggres-
sively market service to insured, healthy workers rather than the poor, sick, and
elderly on whom residents have historically trained; and expanded prepaid
health delivery provides a new incentive for recognition of (cost assignable)
disease from occupational and environmental sources.
Unfortunately, these same forces that guarantee OEM more visibility may lead
to involvement of residents in delivery of routine, cost-effective screening, and
primary care services that serve primarily institutional needs. Such activities are
intellectually stultifying and unlikely to increase the capability of residents to
recognize and treat occupational and environmental disease. Further, the
resident in such contractual settings is unlikely to develop therapeutic relation-
ships with worker patients that resemble the internist's future role in the care of
patients who work.
The alternative is the now proliferating academic OEM clinic model, where
individually referred patients with suspect problems are diagnosed and man
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aged. These clinics offer a highly desirable mix of experiences for the resident.
Problems, however, include the very high cost of such clinics and their still great
scarcity. Thus, some middle alternatives between the inevitable en cl the ideal are
described.
CUR~CULUM APPROACHES TO THE TEACHING OF OCCUPATIONAL MEDICINE IN
FAMILYPRA~ICE RESIDENCIES
Raymond Y. Demers, Anne Cunningham, and Martin I. Hogan
The positive and negative influences of the work environment on human
health are obvious to the trained observer. However, the interrelationship
between work anct health often goes unnoticed or unappreciated by many
primary care physicians. If occupational medicine skills are to be integrated into
community-based practices, they first must be taught and learned during the
time of residency education. The occupational and environmental history is the
foundational too] for discovering the influence of occupation or environment
on the patient. This paper discusses the benefits of and barriers to incorporating
occupational history information into routine patient care and suggests ways to
change family practice residency curricula to include more occupational medi-
cine content.
Incorporating occupational medicine content into clinical practice has
benefits and barriers. Benefits include the gathering of additional information
relevant to the diagnosis and management of disease, and the ability to offer a
unique service that generates additional revenue and that remains in compli-
ance with laws that require the reporting of occupational disease. Barriers also
exist. The occupational history requires an additional time investment in patient
care, and many practitioners have little training in occupational medicine.
Other physicians do not seek involvement in the unfamiliar legal system. Most
importantly, few physicians have ongoing cues to incorporating new behaviors
in occupational medicine into their clinical practice. Programs that seek to
change physician behavior in occupational medicine must emphasize the
benefits of change and seek to minimize barriers.
Changing residency curricula to include occupational medicine content
requires establishing relevant curricular objectives, designating appropriate
teaching strategies, and evaluating the learning needs and outcomes of resi-
dents. Curricular objectives address behavioral assessment of the resident.
Sample curricular objectives would state that each resident must obtain and
record occupational histories on at least half of all adult patients, and attend at
least two industrial site visits per year. Teaching opportunities can either
integrate the occupational medicine content into existing educational activities
(morning report, bedside rounds, clinical wrapup sessions, grand rounds, and
core curriculum activities) or be developed as special educational programs (in
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dustrial site visits, participation in employee health services, providing continu-
ity of care for emergency room referrals for occupationally related illness or
injury, and acquiring Material Safer Data Sheets for selected patients). These
changes in curriculum activities should be evaluated by an initial needs assess-
ment and formative assessment, followed by a summative evaluation inquiry to
assess behavioral and knowledge changes.
CURRENT STATUS AND TRENDS IN REIMBURSEMENT OF OCCUPATIONAL HEALTH
SERVICES FOR WORMERS
Frank Gokismith
Primary care physicians continue to be a major ingredient in the delivery of
health care. The ever present diagnostic issue persists. Once they have diagnosed
occupationally related illnesses, diseases, and injuries, these physicians encoun-
ter particularly difficult patient care and administrative problems. The problems
are not the treatment; often the medical issues involved are very similar to those
of nonoccupational disorders. The problems stem from the payment mecha-
nism for the delivery of the service and the potential disagreement over the work
relatedness of the cause of the problem.
If the condition is jo~related, regular health insurance cannot be used for
payment. The system of workers' compensation must be used. To any primary
care physician this throws up a flag and a general reluctance to treat the patient.
Physicians not familiar with workers' compensation quickly find out why they
should think twice before entering "that world" which includes:
1. Fee schedules for medical services that are well below reasonable and
customary charges (at least in a number of states).
2. Long wait for payment of services, especially when the compensation claim
is contested by the employer's insurance carrier. For contested injury claims the
wait could be ~ year; for occupational diseases the wait could be well over 2.5
years.
3. The worry about being interrogated by the attorney and physician for the
injured worker's employer's insurance carrier as to the work relatedness of the
medical condition for chronic conditions such as heart, back, hernia, and similar
conditions, but especially for illnesses and diseases.
4. If the injured worker is receiving workers' compensation, the employer or
the employer's insurance carrier will be making phone calls to the physician
urging that the worker be judged to be ready to work at his or her previous job
or to be able to work at a light~uty job.
A brief description of the worker's compensation system, the economic policy
field in which workers' compensation reforms are debated, experience of other
countries' social insurance systems, and related issues are also addressed.
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ALTERING PHYSICIANS BEHAVIOR PATTERNS AND SKIM THROUGH EDUCATION
Warren A. Heffron
It is my hypothesis that it is possible to alter physicians' behaviors and to
increase physicians' knowlecige and skills through education. If physicians are to
learn through educational methodologies, it is important that they have educa-
tional learning skills as well as the ability to determine what is needed to be
learned. It is also important that education should be actively sought by the
learner. Plato wrote "education under compulsion has no hold on the mind,"
while a more recent author stated "what is learned with pleasure is learned full
measure."
Specialty societies can be effective in enhancing positive attitudes and behaviors. The
American Academy of Family Physicians has set forward as a positive goal that all
family physicians should not only be initially competent in their medical skills
but should continue to grow professionally during their career. This change has
led to creation of new residency programs. Currently one will need to have
graduated from a residency as well as have appropriate continuing education
documented in order to be a member of the Academy. The Academy has
effectively modified its members' skills and attitudes through educational
processes.
If changeis to beinstituted itisimportant that education takeplace early in the education
of medical students and is best incorporated as a part of the medical school cumcutum.
Some of the earliest attempts to upgrade the medical skills of general practitio-
ners were not successful because they were largely based in county hospitals and
there were no family practice role models present in medical schools nor was this
a significant part of the medical school curriculum. It only became successful
when an academic movement in family medicine was established and role
models were placed on medical schools, strong departments created, and
medical students were positively affected and influencer] to enter this specialty.
Attitudes and behaviors can be taught to stunts, residents, and physicians in practice
but need to be reinforced if these behaviors are to be continued. There have been multiple
studies in the literature indicating that the behaviors of physicians can be
modified. However, if reinforcement is not a part of the learning experience,
physicians' behaviors and attitudes soon revert to what they were before the
education intervention. It is therefore important to have the initial educational
experience followed up with the reinforcement educational experience.
Attitudes and behaviors [earned in medical school can enhance career choice insofar as
primary care specialists are concerned. Medical schools throughout the world have
developed different alternative educational experiences that are designed to
influence the choice of medical students into primary care. It has been the
experience at the University of New Mexico that programs with primary care role
models can indeed influence medical students to enter these specialties.
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DEFINING THE EXTENT OF OCCUPATIONAL RISK
Patricia A. Honchar
A need for estimates of the risk of occupational illness and injury exists in
various areas of occupational health, and most directly in relation to public
health prevention activities. Unfortunately, the data needed to define the extent
of occupational risk are not always available ant! often difficult to obtain.
Information about the occurrence of a particular condition in a defined
population is required, in conjunction with knowledge and evaluation of past
and/or current workplace hazards or exposures that relate to the condition.
Some data like these are available in the descriptions of the 10 leading work-
related diseases and injuries as developed by the National Institute for Occupa-
tional Safety and Health, although a great deal of variation exists in the
derivation en c} completeness of the numbers. Differences in the nature of the
occupational conditions and degree of work attributability contribute substan-
tially to the variation in the data available to define risk. For example, while
reasonable estimates of the prevalence of silicosia in workers in high-risk
activities are available Borg with exposure estimates, the risk of neurotoxic
disorders remains in question. Data available to define risk also are affected by
problems in the clinical recognition of occupational etiologies and the appro-
priate diagnosis of occupational disease.
For the primary care or other practitioner, estimates of risk en c! exposure at
the local and community level may be more practical and useful. A physician with
knowledge of the major local industries in which his or her patients are likely to
be employed, arid the hazardous exposures expenenced by the patients, is more
likely to ask appropriate questions and capture occupationally related diagno
ses.
PREVEN rIoN AND DETECTION OF OCCUPATIONALLY RELATED DISEASES BY
PRIMARY CARE PHYSICIANS: DEVELOPING THE PARADIGM
Thomas E. Kot~ke
Occupational hazards are a significant burden for American workers, and
primary care physicians are a potential resource for prevention and early
detection of occupationally related diseases. A number of attributes will have to
be developed if primary care physicians are to become an effective resource:
knowledge of patient need for service, skills to deliver the service, practice
organization to support the delivery of the service, perceived patient demand for
the service, belief that delivering the service is a professionally legitimate activity,
adequate return to the practice for the invesonent in providing the service,
perceived effectiveness of the service, commitment to providing the service, and
confidence to provide the service.
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If a primary care paradigm that includes the prevention and treatment of
occupational diseases is to be developed, a cadre of committed physicians wall
need to be recruited to address these issues and develop practice models. By
developing the Preventive Cardiology Academic Award program, the National
Heart, Lung, and Blood Institute has recruited a cadre of physicians committed
to developing a paradigm of physicians offering preventive cardiology services.
Individuals with institutional support compete for 5-year awards to clevelop
preventive cardiology curricula and intervention models in their medical
schools. The applicant must devote 50 percent of his or her time to the award,
and the average award is about $100,000 per year. The success of the award is
documented by the recent announcement of a Preventive Pulmonary Academic
Award and a Transfusion Medicine Academic Award by the same agency. It is
suggested that a similar paradigm development program be considered for
occupational medicine by primary care physicians.
OCCUPATIONALAND ENVIRONMENTAL HEALTH CONTENT OF INTERNAL MEDICINE
AND FAMILYMEDICINEJOURNALS
Steven Man and Bernard D. Goldstein
The objective of this ongoing study is to determine the extent to which
occupational and environmental medicine content is present injournals read by
a large percentage of physicians in the fields of internal medicine and family
meclicine. The basic premise of our approach is that the boundaries of the
clinical responsibilities for a practitioner tend to be defined by the contents of
the journals written for the practitioner's field. Chosen for this purpose have
been the Annals ofinternalMediane, the Archives of InternalMedicine, the Amerz can
Family Practitioner, and theJournal of Family Practice For the purposes of this study,
occupational medicine has been defined rather broadly and environmental
medicine rather narrowly.
Analysis of 369 articles, case reports, editorials, and reviews in the two internal
medicine journals revealed that 9 (2.4 percent) had primary occupational or
environmental content and an additional 9 (2.4 percent) hack some minor
component, for example, mention of the role of sunlight in the causation of
malignant melanoma. When case histories were presented, only 7.4 percent
listed the occupation. A similar analysis of 491 items in the two family medicine
journals showed that 28 (5.7 percent) had primary occupational or environ-
mental content, and an additional 9 had some minor component identified. Of
the far fewer case histories presented in family medicine journals, 23.0 percent
listed the occupation. We observed numerous instances in which, despite a clear
potential for an occupational or environmental causation, there was no mention
of such causes in the discussion of the case nor was the occupation listed.
Of note is the most common occupation considered in the published
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material, that of health care workers. Similarly, in the few instances that
occupation is listed as part of a case history, it is very often a nurse, physician, or
other health care worker. This may reflect opportunity. It may also reflect some
degree of a self-centered view of the potential for occupation-induced disease.
We recommenct that editors make an effort to increase the extent to which
editorials, reviews, and other features that they tend to control have occupa-
tional and environmental content. In general, such material lags behind the
amount of accepted articles and case material published in theirjournals. This
should signal the willingness to accept for renew original publications in these
areas and thereby increase the likelihood of attracting such manuscripts.
Furthermore, reviewers and editors should begin insisting on a listing of the
occupation in all case histories. This can often be done with ~ or 2 words in the
first line of what is often a 50~ to I,OO~word case history.
IMPROVING MEDICAL SCHOOL EDUCATION IN OCCUPATIONAL HEALTH:
WHAT SHOULD WE TRY TO DO AND HOW SHOULD WE TRY TO DO IT?
Barry S. Lit
All practicing physicians have a need to better understand the relationship
between health and work and to adequately recognize, diagnose, treat, and
prevent work-relatect illnesses en c] injuries. Training needs to take place at all
levels of education. Surveys have indicated that, while improving, medical school
education in occupational health is inadequate.
In order to improve medical school education in occupational health, three
areas, in the author's opinion, should be focused upon: taking and interpreting
an occupational history; identifying and instituting preventive measures for
both the patient as well as other workers who may face similar risks; and
appreciating the context of work and actual working conditions of individual
patients. Training in these three areas should begin in medical school and be
continued in more depth in residency and continuing education programs.
I believe that three words are key in guiding implementation of this proposal:
mainstreaming, cooperation, and reality. Occupational health teaching should
be done in the context of what students perceive as mainstream medicine, and
this teaching needs to be done in almost all clinical departments as well as some
basic science departments. Faculty member cooperation within and among
departments is essential to facilitate this. Students need to have real-world
contact with patients with work-related medical problems, as well as with the
working conditions and workplaces that cause or contribute to occupational
medical problems.
Finally, teaching should focus on work-related disease and its recognition arid
prevention, and not emphasize so-called health promotion and life-s~le-related
programs in the workplace. The precious little time for occupational health
should focus on work-related medical problems.
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NEW INFORMATIONT TECHNOLOGIES FOR MEDICAL PRACTICE
Daniel R Masys
The rapid pace of discovery in the life sciences is reflected in a growing flood
of information published in the biomedical literature. The last 10 years have
seen a doubling of the journal articles indexed by the term OCCUPATIONAL
DISEASE in the MEDLINE data base, from ~ ~ ,220 in 1977 to a cumulative total
of 24,759 by the end of 1986. With nearly 2,000 new articles per year being
published in this subject area alone, and the entire MEDLINE file growing at
over 320,000 new entries per year, it is not surprising that the primary care
practitioner is unable to maintain a comprehensive and current understanding
of the diagnosis and therapy in specialized disease areas such as occupational
and environmental health.
A number of new information technologies have arrived in the marketplace
within the past 5 years that have the potential to substantially enhance the
problem-solvir~g strategies of health care professionals. These technologies
include increasingly powerful and inexpensive personal computers, mass infor-
mation storage devices such as magnetic and optical disks, and affordable digital
telecommunications for online access to biomedical data base systems. There
are currently three types of electronic information resources that are useful in
clinical problem solving: bibliographic search systems, factual data bases, and
artificial intelligence or expert systems.
Bibliographic search systems are the best known and most widely used
currently; MEDLINE is searched over 3 million times per year by online users
around the world. Computerized bibliographic systems are an indispensable aid
in locating publications, but provide only a pointer to information that is
physically located elsewhere, or at best provide an abstract of the publication's
content.
Factual data bases differ from bibliographic data bases in that they contain the
information sought. Several factual databases are available from the National
Library of Medicine's MEDLARS computer: TOXNET, a suite of toxicology and
environmental hazard data bases, and the Physician Data Query (PDQ) system
of cancer treatment advice. In both bibliographic and factual data bases,
searches presume that the user has an awareness of a specific concept or disease;
they do not generally instill such awareness in the user. Since lack of awareness
of the possibility of occupational and environment illnesses appears to be a
central issue in primary care delivery, such online systems would not be expected
to have a major impact in improving outcomes.
Expert systems are those computer programs that embody the knowledge of
human experts in goalMirected reasoning processes. A number of prototypes
have been constructed, such as the MYCIN antibiotic selection advisor, its
successors PUFF (pulmonary disease) and ONCOCI1~ (oncology) clinical advi-
sory systems, and the diagnostic expert systems CONSIDER, RECONSIDER, and
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CADUCEUS (INTERNIST-I). Rules for diagnosing occupational and environ-
mental illness exist in most of the current general purpose expert systems
developed for medical diagnosis, and the ability of such systems to methodically
and rapidly evaluate hundreds or thousands of candidate diagnoses based on
clinical findings offers a new tool for improving the consistency and accuracy of
clinical diagnoses. Expert systems are in development and testing stages now
and will be available widely in 5 to 10 years.
CHANGING PHYSICIAN BEHAVIOR: A SYSTEM~MARKETING APPROACH
Graham W. Ward
A physician is embedded in a complex social system. The actions of a given
physician are influenced as much by the forces operating in his or her system as
by the knowledge he or she may possess. To modify physician behavior, we must
use social marketing to gain the initial interest of the primary care provider in
the problem, to persuade the primary care provider to gain the knowledge
required for an appropriate response to a problem, and to reinforce the actions
the primary care provider must undertake so that they occur regularly on a Tong-
term basis.
Marketing uses interventions arising from target audience needs, wants, and
expectations. Three activities are required: defining the problem in marketing
terms, developing a strategy based on the problem definition, and exploring
some considerations related to implementing the strategy. A key task is segment-
ing the market, that is, identifying sectors within a population to allow priorities
to be set and to permit development of messages tailored for specific groups.
Before a solution can be proposed, one must know why the inappropriate or
lack of action exists. Marketers analyze the situation using the four "P's" of
marketing: product, place, price, and promotion. Place addresses the question:
Are the materials and services needed to solve a problem located properly in the
system?
Price is a set of ratios The first is the ratio of the price to perceived utility. This
means there are two opportunities to seek change that reduce costs as a barrier
to consumer action. One is to reduce the actual price, for example, by lowering
the cost of continuing medical education attendance or records systems.
Another is to increase the perceived value so the price does not seem to be so
great. The second is the ratio of the value gained in a transaction relative to the
value of other foregone transactions the "opportunity cost."
Promotion has two components, visibility arid timing achieving awareness
that an option exists and reinforcing that option at the time the user is making
. . .
a neclslc~n.
cow ~
Roses. A description of a professional's role must meet two requirements:
rationality and specificity. Basic physician education is limited to achieving
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expertise in only two functions: critical diagnostic (physiologic abnormality
identification) decisions and critical therapeutic (medical interventions deci-
sions. Planners err by casting physicians in nonmedical roles. A rational am
proach is, first, to define the skills, knowledge, and experience required for a set
of tasks and, only then, to surmise what type of professional or team of profes-
sionals best fits the needs of the tasks. Start with a medical role for the M.D.
Specificity. Defining the role of a profession or organization requires a high
degree of specificity that is usually best achieved by consensus. Examples of
important role questions are: What history items should be probed routinely?
What special history items should be probed in what special circumstances?
What diagnostic procedures should be routinely part of baseline data? What
sentinel events should one watch for? What educational information should be
given to patient~routinely and under special circumstances? How and when
should communications be established with a patient's company physician?
When and to whom should what patients be referred? What knowledge or skills
should physicians seek to improve?
90
Representative terms from entire chapter:
occupational health
