An anatomy of occupational medicine

Lee, W. R. (1973).British Journal of Industrial Medicine,30, 111-117. An anatomy of occupational medicine. Previous writers have attempted to describe occupational medicine by considering the functions of a doctor working in industry. In different communities, and even in the same community at different times, a doctor working in industry may have different functions. `Occupational medicine', so described, would therefore not be a discipline but would merely be medicine practised in a certain area. Furthermore, such an approach leaves out other aspects of occupational medicine such as recompense for injury at work and statutory supervision of workplaces, and any interaction between these two.

Men think in terms of conceptual models which predetermine to a greater or less extent their approach to future problems. The present essay attempts to formulate a coherent intellectual framework of occupational medicine.

The conceptual model proposed here is based on the globe proposed by Himsworth (1970) as a model representing the structure of scientific knowledge. Using this, a place for occupational medicine can be determined related to medicine, industry, and the `basic' sciences. Occupational medicine is thus seen as a coherent entity.

The argument is supported by a comparison of some of the provisions for occupational medicine in this country and in France. In this comparison the underlying components are distinguished from the mechanisms set up to deal with them. It is these components which go to make up the structure of occupational medicine and it is the coherence and close relationship of them which must be studied to find and describe an entity to be called occupational medicine.

     

The importance of intuition in the occupational medicine clinical consultation.

Clinical consultation involves unspoken elements which flow between doctor and patient. They are vital ingredients of successful patient management but are not easily measured, objective or evidence-based. These elements include empathy and intuition for what the patient is experiencing and trying to express, or indeed suppressing. Time is needed to explore the instinctive feeling for what is important, particularly in present day society which increasingly recognizes the worth of psychosocial factors. This time should be available in the occupational health consultation. In this paper the importance of intuition and its essential value in the clinical interview are traced through history. Differences between intuition and empathy are explored and the use of intuition as a clinical tool is examined.     

Tropical medicine consultation

Tropical medicine consultations are fully justified in settings with the latest modern technology, where specific complementary tests are available and there are professionals with experience in tropical questions. That is to say, in tertiary hospitals. If such consultations took place in secondary hospitals or in primary care, they could be considered inefficient or unjustifiable from the point of view of the volume of patients attended to. However, there is a care deficit with respect to preventive activities concerning travellers or immigrants who have recently arrived from countries with a low income and where there is a high prevalence of imported diseases that are less recognised in our normal health milieu. Thus, international health units, which combine preventive and curative activities in a framework of public health provision and in a functional situation between the hospital level and that of primary care, offer a more efficient and suitable profile for the characteristics of the Spanish population. Their implementation depends on policy makers, the offer of a realistic portfolio of services, the existence of quality control monitoring and the possibility of managing information through a computer network.     

An audit of occupational health care for employees with low-back pain

Guidelines for occupational rehabilitation of workers with low-backpain were developed as part of a larger study. We have formulatedcriteria for good practice of occupational rehabilitation onthe basis of these guidelines. To assess the quality of occupationalrehabilitation in the Netherlands, these criteria were subsequentlyused in an audit of medical records. The number of patientswho received care consistent with the guidelines was comparedto the number of patients eligible to receive that kind of care(performance rate). Six performance rates were calculated fromthe medical files of 40 workers with 48 new episodes of low-backpain. Two performance rates proved to be below 25% and two almost50%. The highest performance rate, that for curative policy,was 90%. These results are discussed in the light of the reliabilityof the original data. We recommend construction of guidelinesas well as reliable registration of the occupational rehabilitationprocess to increase the possibilities of auditing and to raisethe quality of occupational health care.     

An international consultation: the development of family medicine in Vietnam

An effective international consultation on health system reform can be approached using the five-step process of establishing goals, conducting a needs assessment, defining objectives, developing methods, and designing evaluation strategies. This structure provided guidance to a consultation we provided to the Ministry of Health, Socialist Republic of Vietnam (SRV) to review its current health care delivery system. The consultation examined all levels of health care delivery and medical education. The SRV has an extensive, but poorly staffed, "commune health center" system. There is a widespread perception that the quality of medical care is low in these health centers. People leave their communities to obtain health care elsewhere at more-specialized levels and more-expensive sites. Our consultation included an analysis of the potential effect of creating a primary health care delivery system based on the model of family medicine. In addition to consulting, part of the time spent in Vietnam was used to advocate for changes in the system to allow for movement toward a primary health care delivery system. The consultation culminated in the creation of the specialty of family medicine and in the establishment of the medical education system to train family physicians.     

An audit of NHS Trust alcohol policy referrals to an occupational health service

An exploratory review of 33 referrals to an Occupational Health Service of employees with alcohol problems provided information on age and sex, job category, mode of referral, medical and social problems and outcome. Case records were examined providing information on clinical assessment and the treatment options. The high rates of relapse, drop-out and refusal of help, supported the view that this population had serious alcohol problems. Clinical recording by occupational physicians showed a marked variability. No doctors were included in the sample although this group is known to be vulnerable. Blood testing was used infrequently. Occupational health clinical practice could be enhanced by the use of clinical protocols, systems of morbidity recording and co-operative studies with other agencies. Further prospective studies are needed.     

Hospital records: An underutilized source of information regarding occupational diseases and exposures

A 1993 study examined the association between pneumoconiosis and cor pulmonale using a computerized data base of hospital records in Ontario (Hospital Medical Records Institute, HMRI). The present investigation was undertaken to confirm the coding of the diagnoses of a subset of the hospital discharges from that study, to determine the validity of the coding of the diagnoses of coal workers' pneumoconiosis (CWP), and to identify work exposure (occupation and industry) information available in hospital records. We sent abstraction forms to hospitals for 521 subjects who were hospitalized for pneumoconiosis, cor pulmonale, or both conditions, requesting information regarding diagnoses, occupation and industry data, and X-ray results. Abstracts were received for 720 (76%) of 944 discharges that were sought. The hospital abstractions confirmed the HMRI coding for 90% of the charts with these conditions, including 63%, 97%, and 96% of discharges for CWP, silicosis, and asbestosis, respectively. Specific dust exposures were indicated in 42% of the charts with a code indicating a diagnosis of CWP, and of these, 67% indicated exposure to coal dust. Of charts with a code indicating a diagnosis of silicosis, 73% with specific dust information indicated silica exposure, and 95% of those for asbestosis indicated exposure to asbestos. Of 34 individuals in this data set known from the Ministry of Labour's Chest Clinic X-ray Surveillance Program of miners to have silicosis, 33 (97%) were diagnosed by the hospitals as having pneumoconiosis, and all but two were silicosis. Hospital records, as reflected by HMRI data, are reliable indicators of cor pulmonale and pneumoconiosis. The agreement with the Chest Clinic's X-ray diagnoses provides additional objective confirmation of the accuracy of the hospital information. There were relatively few cases of silicosis miscoded as CWP. At least for pneumoconioses, hospital records contained information about the exposures that led to these diseases in ∼50% of the cases. However, whether hospital records would prove useful for detecting other work-related conditions that are not pathognomonic of occupation is not known. The importance of taking occupational histories needs continued emphasis in medical education and training. Am. J. Ind. Med. 31:100–106 © 1997 Wiley-Liss, Inc.     

Travel medicine consultation: An opportunity to improve coverage for routine vaccinations

BackgroundTravelers may be responsible for the spread of vaccine-preventable diseases upon return. Travel physicians and family physicians may play a role in checking and updating vaccinations before traveling. Our aim was to evaluate the vaccine coverage for mandatory and recommended vaccination in travelers attending a travel medicine clinic (TMC).MethodsVaccine coverage was measured using the current French immunization schedule as reference for correct immunization, in travelers providing a vaccination certificate during the TMC visit (university hospital of Saint-Étienne), between August 1, 2013 and July 31, 2014.ResultsIn total, 2336 travelers came to the TMC during the study period. Among the 2019 study participants, only 1216 (60.3%) provided a vaccination certificate. Travelers who provided a vaccination certificate were significantly younger than travelers who did not (mean age: 34.8 ± 17.8 vs. 46 ± 18.4 years, P < 0.005) and were less likely to be Hajj pilgrims. Vaccine coverage against Tetanus, Diphtheria, and Poliomyelitis (Td/IPV vaccine) was 91.8%, 78.6% against Measles, Mumps, and Rubella (MMR), and 59.4% against Viral Hepatitis B (HBV). BCG vaccine coverage was 71.9%. Older travelers were less likely to be correctly vaccinated, except against HBV as vaccinated travelers were significantly older than unvaccinated travelers.ConclusionObtaining information about immunization in travelers is difficult. Coverage for routine vaccines should be improved in this population. Travel medicine consultations could be the opportunity to vaccinate against MMR, HBV, and Td/IPV.     

Audit in occupational medicine: an audit of fitness to drive among voluntary drivers in an NHS trust

BACKGROUND: A health surveillance programme, to assess fitness to drive, was initiated for voluntary drivers in an NHS Trust because of reports of increasing frailty and slow reactions among some drivers. After discussion between the occupational health department, voluntary services manager and personnel department it was considered appropriate to apply Driver and Vehicle Licensing Authority (DVLA) Group 2 fitness to drive standards to those voluntary drivers who drove the Trusts minibuses. RESULTS: An audit of the initial health surveillance of 47 drivers is presented. The mean age of the voluntary drivers was 66.4 years. A large number of medical problems with the potential to affect driving were discovered (average of 1.9 medical problems per driver).The outcome was that five voluntary drivers were found unfit to drive the hospital minibus and one voluntary driver was found unfit for car driving. CONCLUSIONS: A fitness assessment form for drivers is presented. This form is primarily for the use of occupational health nurses, to help them to decide when referral to an occupational health physician is indicated.     

Evidence-based clinical occupational medicine: updating the ACOEM occupational medicine practice guidelines

In this article, we review the evolution and application of evidence based medicine and the results of the literature reviews and syntheses incorporated in the second edition of the guidelines. Our intent is to disseminate this information to practitioners treating injured workers and those managing and financing such care and disability management. Use of proven diagnostic, causality, testing,and treatment methods should markedly improve the quality of occupational medical care and make that care more cost effective.     

Confidentiality in occupational medicine

Confidentiality of personal medical information is a serious concern in occupational medicine. New regulations issued under the Health Insurance Portability and Accountablility Act (HIPAA) significantly alter procedures for protecting and managing confidential medical information. There are still questions about how much the new regulations will affect occupational medicine practices, but there will be significant changes in the collection, storage, and dissemination of personal medical information in the near future. The implications of increased confidentiality concerns on research are also considered.     

Auditing occupational medicine.

An important challenge facing the quality of practice in occupational medicine is a limited evidence-base, but equally important is the need to translate good evidence into high quality practice. Audit has an important role to play in addressing the determinants of variations in practice. Furthermore where the evidence is good enough to permit the development of valid practice guidelines, audit may help in improving education and standards of practice. External audit may have a role to play in ensuring conformity with service-level agreements and especially in addressing issues of quality which some management systems may fail to address. As more literature is published reviewing and achieving a consensus on the evidence-base for the practice of occupational medicine, and as more experience in audit is described, it can make an important contribution to quality in occupational medicine.