Occupational and Environmental Medicine: What the Future Holds

1. Occupational and Environmental Medicine: What the Future Holds Tee Guidotti Past President American College of Occupational and Environmental Medicine

2. Occupational Medicine • A small specialty but a large field of practice, with many practitioners entering “laterally” in mid-career: a source of strength! • A patient-care function, combining clinical care and prevention, but not sensitive to changes in medicine or healthcare delivery • A public health function: combines individual care and population health management • Caught up in employment, economics and national security • Largely supply-driven, not demand-driven • Has been on an upswing recently • Many more, better jobs in recent years • Strong demand for services • OM practice is very attractive • High physician satisfaction • Sometimes combined with urgent care • International/global practice

3. Traditional Core Functions • Acute treatment, follow-up care • Fitness to work • Disability management • Workplace-centered prevention • Occupational disease, toxicology • Disease and periodic health surveillance • Population health management • Disaster response, planning • Regulatory compliance • Review workers’ comp claims • Prevention and hazard evaluation

4. Occupational Medicine is a Preventive Medicine Specialty

5. Work and Health • Work-related disorders (clinical, prevention) • Work-aggravated disorders (clinical, prevention) • Disorders and conditions affecting work capacity (disability) • Productivity and health (absence and presence) • Health risk assessment (OH function) • Anticipating future health risk (consultative, loss prevention) • Causation and liability (medicolegal) • Managing enterprise health issues (the “chief health officer”)

6. Pillars of OEM • Causation • Fitness for duty (includes impairment assessment and disability management) • Exposure (human  environment interface) • Prevention • Health protection in the workplace • Wellness • Population and individual health management

7. Unique Services of OEM • Occupational history and exposure assessment • Impairment evaluation • Medicolegal services • Program management • Fund of knowledge in occ/env hazards

8. Diversity of Practice Settings • Employer • Corporate medical department • Plant, full- or part-time • Military • Consultant • Community practice • Clinic, Hospital-Based • Government (state, local) • Academics

9. Where We Practice

10. The Physician-Patient Relationship

11. OEM and Social Justice Two Noble Traditions in the Progressive Era (around 1920) Alice Hamilton Led in scientific OM and workplace prevention Harry E. Mock Led in OM practice and health promotion

12. A Heroic Figure Irving J. Selikoff 1915 – 1992 Exemplary physician, scientist, and visionary. Best known for his work on asbestos but he also did much more in a long career. He inspired a generation of occupational physicians.

13. Essential Roles for OEM • Occupational health services comprise a total system • Primary care • Specialty care • Program management • Population health management • A parallel healthcare system, with different capabilities and drivers • Workers’ compensation • Employer-sponsored services • OSHA-mandated surveillance and regulation • Leads in occupational dimension of patient mgmt • Important line of defense against questionable practice • OEM physicians are public health professionals for the employed population.

14. Occupational Medicine is a System, Not Just A Practice

15. Value added Liability and rising healthcare costs Regulatory policy Workers’ comp reform Preparedness activities Productivity and wellness Mid-career entry into practice (credential gap) “Paradigm” of medical education, training Supply, demand imbalance Changes in technology Changes in economy Changes in workforce Changes in regulation What’s driving the future of OEM?

16. Environmental Medicine • Great potential for intellectual contribution • Similar content in tox, physical exposures • Similar methodology in env, occ epi • Important role in countering unproven or speculative practice (inc. quackery) • No viable practice model • Litigation support • Regulatory functions • Public health functions Anton Chekhov, the playwright, was a physician, a public health expert, and an environmentalist. His big issue was forest conservation.

17. The OEM Physician Workforce • AMA estimates 10,000 physicians who do some occupational medicine • 3,332 Board-certified occupational medicine physicians since 1955 • 1,500 - 1,800 are actually in practice • National need - 5,000 • Bureau of Health Professions needs estimate - 4,830 • Institute of Medicine needs estimate - 3,100 - 5,500 • My estimate: 4,000, because of changes in US workforce I am on record: US should be training 237 occupational physicians per year.

18. Current Training Model is Obsolete • Clinical year • Primary care specialty • Family medicine, internal medicine most popular • Pediatrics and emergency medicine not uncommon • Didactic year • MPH program or its equivalent. • Practicum year • Field experience Likely to change but it will take a while.

19. Favorable New Trends in OH&S: Long term • Different ideas regarding labor, management • Retirement of many USPHS professionals • More fluidity in health care system • In-plant clinics a big new trend • Healthcare and WC reform • Emphasis on better outcomes • Costs to nation under scrutiny • Push for evidence-based practice • Emphasis on sustainability • A new attitude toward regulation on the rebound?

20. Not worksite health promotion Essential in an era when two workers support every retiree (2030) v. 3.3 today Developed countries face a crisis in productivity Workers will need support to work longer Disability will be perceived as problem of social stability, not only as case management Quality of working life becomes a profound issue Better outcomes for injured workers Medicare is much worse off Health and Productivity

21. A New Concept for OEM and for OH • OEM physicians are public health professionals for the employed population. • OH/WC constitute a parallel healthcare system, with different capabilities and drivers • OH services – a “triple threat”? • Support productivity • Protect workers health • Protect the future of the enterprise • Rethink “environmental medicine” • Core service • Corporate or enterprise “chief health officer” • CHO in C-suite: broad responsibilities

22. Emerging Core Functions for the “Chief Health Officer” (CHO) • Manage relations with health care system • Population health management • Environmental consultation • Risk assessment and management • Emergency preparedness • Travel medicine • Clinical and mgmt internal consultant on complex cases: • Occupational and environmental toxicology • Musculoskeletal disorders and ergonomics • Disability management • Global health services • Workers’ compensation management

23. The Way Forward • Versatility and problem-solving skills • Management expertise, cross-training • Changes in economy and social structure create opportunities as well as problems • Keep eye on the long term; manage in the short term • Add value and better outcomes, not just savings • A strong and ethical organization leading OEM • Maintain identity as a public health field • A new generation of OEM physicians sensitive to social justice