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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. 78

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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 /9

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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. SO

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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 81

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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 82

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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. 83

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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. 84

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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. ~5

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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 86

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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. 87

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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 88

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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 89

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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