Occupational health in general practice in an industrial area of Singapore

The aim of this study was to estimate the caseload with regard to the proportion of work-related medical cases in factory workers and to survey knowledge of and attitudes to occupational medicine among doctors in an industrial area in Singapore. To this end, a self-administered questionnaire was given to 74 general practitioners in the industrial district of Jurong in Singapore. Overall, there was an 89.2% response rate. Thirty-three of the 66 respondents were males. Mean age was 40.8 years (range 27-64 years). Twenty-four (36%) had some postgraduate training in occupational medicine (GP-OM) while the rest did not (GP). The caseload for all doctors was similar with regard to the number of adult patients and, more specifically, the number of factory workers seen per day. The majority of doctors (76.6%) felt that <10% of factory workers seen had work-related problems. Most (70%) felt confident in dealing with the occupational problems that arose. However, a large percentage (78% of GPs, 45.8% of GP-OMs) felt that training in occupational medicine was inadequate. This is reflected in the knowledge questions, where GPs did not score as well as GP-OMs. It was concluded that GPs working in this industrial area see a good proportion of factory workers, in a fair number of cases for work-related problems. However, only a third of the GPs are qualified in occupational medicine. These factors highlight the need for more emphasis on occupational medicine training among general practitioners, especially those working in industrial areas.     

Occupational asthma: a community based study.

The incidence and prevalence of occupational asthma has been extensively studied in industry settings and specialist clinics. However, it has been much less studied in the community. This study looked at the general practice notes of asthmatics in an attempt to assess the overall load of occupational asthma in the community. Eighty-six per cent of the patients with adult onset asthma in the practice population studied had at least one occupation recorded in their notes. Nearly a third of these (32%) were in jobs known to be significant causes of occupational asthma, yet a potential link between their occupation and symptoms had only been recorded in 18% of patients in these jobs. Overall 4% of the patients with adult onset asthma had been given a diagnosis of occupational asthma although in nearly half these cases the diagnosis had been made by a general practitioner and not a specialist.     

The estimated workforce served by occupational physicians in the UK

During the past decade, an occupational disease surveillance scheme has been created in the UK, based on systematic reporting of newly diagnosed cases by six groups of clinical consultants and by specialist occupational physicians. Labour Force Survey statistics have proved a reasonably satisfactory denominator for the former, but not for the occupational physicians, who provide services for only a selected subsection of the employed population. To remedy this deficiency, approximately 700 occupational physicians who were recorded as having been a reporter at some time were invited to provide their best estimate of the number of employees for whom they were responsible. After various exclusions--mainly physicians who were not, or were no longer, responsible for any defined workforce, and others who had not reported for at least 3 years--the number of active participants for whom data, by industry, occupation and sex, were obtained or estimated was 503. The resulting total number of employees served was estimated at 3.2 million, comprising 12% of the general working population. The proportion with access to an occupational physician varied enormously, from 43% in the health and social services to 1% in agriculture, forestry and fishing, and 6% in the rest of industry. Numbers estimated for each industrial sector were fairly reliable, but by occupation less so, especially in the health and social services.     

Developments in education in occupational medicine in the United Kingdom

Postgraduate medical education in the United Kingdom has changed. Now, five years of undergraduate training merely prepare a doctor for postgraduate training, whatever his specialty will be. After undergraduate training (and a year in hospital) all doctors do three years General Professional Training followed by some four years Higher Specialist Training. Occupational physicians do the same General Professional Training as physicians or primary care general practitioners. Their Higher Specialist Training lasts four years and is based on supervised practical experience in the factory or other place of work. After the first two years of this they take an examination covering the broad field of occupational medicine (AFOM). After the next two years of supervised practical experience the doctor has to present evidence of special study and can then become a specialist (MFOM). In the U.K. about 70% of occupational physicians work part time. Their supervised practical experience is therefore spread over a longer period. Many stop at the AFOM. If, later in their career, they change to full time in occupational medicine, they can proceed to the specialist qualification (MFOM). Most part-timers do other work and therefore cannot go away to one of the few universities that provide courses for the AFOM. Those who live near one of the few universities can go on day release. A “distance teaching” project has been started to take teaching material on occupational medicine such as audio tapes, tape slides, and video tapes to these doctors. It will be supplemented by local seminars and short courses at universities.     

Surveillance of Australian workplace Based Respiratory Events (SABRE): notifications for the first 3.5 years and validation of occupational asthma cases

AIMS: In Australia, the SABRE programme, a notification scheme, has been established to collect incidence data on occupational lung disease. This paper reports the first 3.5 years of this scheme and the results of an occupational asthma validation study. METHODS: A notification form is mailed regularly to thoracic physicians and occupational physicians in the Australian states of Victoria and Tasmania, who use this to report new cases of occupational lung disease. The validation study was performed by a blinded panel of two doctors, who reviewed information extracted from the medical files of a sample of reported cases of occupational asthma. RESULTS: A total of 520 diagnoses were reported. The mean (+/- SD) age of the 448 patients notified was 55.7 +/- 16.2 years. There were 394 (88%) males and 54 females. The most common single condition was asthma for which the most common causative agent was wood dust. However, the most commonly reported agent overall was asbestos. The validation study of occupational asthma found only fair agreement (kappa = 0.4) between the panel and notifying doctors. However, agreement was better (kappa = 0.5) when the analysis was restricted to those cases where the reporting doctor considered the likelihood of the diagnosis was high. CONCLUSIONS: Occupational asthma is the most common occupational respiratory condition reported, which suggests increasing importance for this disease over more traditional forms of occupational lung disease. The validation study suggests that such schemes should restrict notifications only to those cases where the likelihood of the diagnosis is considered high.     

Occupational eye injuries: a continuing problem

Background Ocular trauma is a worldwide cause of visual morbidity,a significant proportion of which occurs in the workplace. Thisis largely preventable with the use of protective eyewear andstrict compliance. Aim To analyse the type of occupational eye injuries that occurand to document the use of eye protection in patients presentingto a UK district general hospital. Methods A pilot retrospective case note analysis of all ocularinjuries seen in one calendar month was performed. A prospectivesurvey of consecutive occupational ocular injuries presentingto this district general accident and emergency (A&E) departmentover a 2-month period was then carried out. Demographics, aetiology,eye protection usage and clinical details were recorded andanalysed. Results Of all eye patients attending this A&E, 31% (87/283)were due to occupational eye injuries. Of 55 prospectively reviewedpatients with occupational eye injuries, the majority had minorinjuries. Of the cases where eye protection was recorded, 56%(18/32) were not wearing any protection and 44% (14/32) woreeye protection at the time of injury. Conclusions Occupational eye injuries are a commonly seen ocularcomplaint in the A&E department. Provision of appropriateeyewear protection and worker education is required to minimizethe incidence of ocular injury in the workplace.     

Occupational health services in the UK--challenges and opportunities

BACKGROUND: A small minority of the UK workforce currently has access to an occupational physician. Reduction in the size of enterprises, the emergence of atypical work patterns and problems recruiting and training occupational health specialists risk making this minority even smaller. AIM: This paper considers the challenges currently facing occupational medicine and how we can improve access to occupational health services (OHS). It aims to highlight some of the diverse internal and external factors that restrict the UK's ability to provide all workers access to OHS. METHOD: A literature review was carried out and combined with awareness of current trends in business and new legislation together with provision of occupational medicine in other countries. RESULTS: Potentially controversial solutions that might help to make OHS more widely accessible were identified and are discussed. It is hoped that these will provoke further debate. CONCLUSION: Individually and organizationally, we must examine and improve capabilities if we are to improve worker access to OHS and deliver targets to reduce occupational ill-health. It is suggested that this requires a strategic shift to apply resources differently. There is need to explore delegation of tasks traditionally performed by doctors to nurses and other staff together with the outsourcing of non-core work. The increased use of telemedicine and the enhanced use of information technology for training, risk assessments, wellness programmes and questionnaire-based health assessments are other developments that should be explored.     

Communication between an occupational physician and other medical practitioners--an audit

Four hundred and seventy-two consecutive referral episodes relatingto 386 patients attending the Occupational Health Departmentof a general teaching hospital were analyzed to evaluate thefrequency, content and effect on management of communicationsbetween the occupational physician and other doctors. In all,250 episodes (53%) were associated with such a communication.The likelihood of a communication was strongly influenced byreason for referral, particularly in respect of long or shortterm sickness absence; univariate odds ratios (OR)=10.58, 95%Cl=8.13–27.08) and 2.65, 95% Cl=1.55–4.60) respectively;a medical diagnosis of psychiatric illness (OR=3.17, 95% Cl=1.69–5.97));and by number of consultations. Communication was also morelikely when the occupational outcome was ill health retirement,rehabilitation in work or modified work. Ninety-eight per centof specific requests for information or an opinion eliciteda reply. Information received from other doctors influencedthe occupational health physician's management in 52 referralepisodes (20%). Specific action by GPs as a result of communicationwas documented in 54 and by specialists in 37 episodes. Theimportance of communication between occupational health physicianand other doctors in the occupational health process is confirmed.     

Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload

BACKGROUND: Professional expectations for communication skills are explicit. These skills are needed for professional integrity and personal morale. Nevertheless, occupational physicians see doctors as patients for whom communication among between doctors and with their managers are the principal cause of their presenting health problems. AIM: To describe the frameworks of professionalism in medicine and the duty to care for good communication; present issues surrounding competency in communication skills; identify health problems among doctors associated with poor communication; and consider roles of economic appraisal and preventive strategies. METHOD: A literature review identified key publications of professional expectations and requirements of doctors for their communication skills. Health problems among doctors associated with poor communication and presenting at least twice in a National Health Service (NHS) occupational health (OH) department during January-December 2002, were sought by manual retrieval of all doctor-patient records. The categories of communication difficulty were agreed in the focus group discussion of the presenting problems with occupational physicians. RESULTS: Nine categories of communication difficulties among doctors resulting in their presentation in OH departments with health problems were identified. CONCLUSIONS: Personal health problems caused by poor communication involve considerable time and potential litigation costs. Doctors need to be reminded of their responsibilities. Opportunity cost studies would help to strengthen an evidence base for the need of doctors to adhere to the professional requirements of good communication skills.     

The effect on attendance rates for sickness absence assessment of a revised employee information sheet

BACKGROUND: An increasingly high standard of ethical practice is expected of all doctors and in particular those not providing treatment services. AIMS: This case-control study investigated the effect on non-attendance rates for first sickness absence appointments of a new employee information sheet sent to staff from the two largest departments, education and social services, of a large UK local authority. METHOD: An information sheet detailing the ethical standards applying to a local authority occupational health service was developed and sent to all employees referred by their managers as part of the sickness absence management procedures, along with details of their appointment. RESULTS: A reduction of approximately 1/3 in the rate of non-attendance was noted in the intervention group, which was statistically significant for social services referrals. CONCLUSION: This approach may improve the efficiency and effectiveness of occupational health services, as well as helping to achieve the informed consent of employees undergoing occupational health assessment.     

Influence of work environment on emotional health in a health care setting

BACKGROUND: Radical changes are taking place in health care services and might be expected to cause job dissatisfaction, absenteeism, somatic complaints and mental health problems. Research in this area is limited and focused primarily on nurses. AIM: To understand the impact of the work environment on the emotional health of doctors and nurses in a general hospital setting. METHODS: Cross-sectional study using self-reported questionnaires including the General Health Questionnaire, the Posttraumatic Stress Disorder (PTSD) Checklist for Civilians, the Trauma Experiences and Work Environment Scale. RESULTS: The response rates for the study were 28% (60) for doctors and 54% (431) for nurses. Whilst the prevalences of psychiatric disorder, anxiety, depression and PTSD were higher for doctors compared with nurses, this was not statistically significant. Both groups reported witnessing someone badly injured or killed as their most distressing experience (doctors 46% versus nurses 41%). Using multiple logistic regression, significant predictors of emotional health was task orientation for doctors (OR = 1.96, 95% CI = 1.1-3.6), and PTSD (OR = 17.2, 95% CI = 6.0-49.6), work pressure (OR = 1.2, 95% CI = 1.01-1.4) and innovation (OR = 0.81, 95% CI = 0.70-0.94) for nurses. CONCLUSION: The prevalence of psychiatric disorder among the doctors and nurses was similar to that in Britain. Elements of the work environment did impact on the emotional health of health care workers. Organizational development initiatives should include employee mental health issues in order to create a more positive work environment.     

Accidental blood and body fluid exposure among doctors

Aim To study the epidemiology and time trends of blood and bodyfluids (BBF) exposures among hospital doctors. Methods A 3-year study was carried out using data from the ExposurePrevention Information Network of four teaching hospitals inthe UK. Results One hundred and seventy-five cases of BBF exposuresin doctors were reported over the 3-year study period. Eighty-one(46%) occurred in senior doctors and 94 (54%) in junior doctors.Junior doctors had a higher rate of BBF exposures compared tosenior doctors: 13 versus 4 incidents per 100 person-years,respectively (relative risk 3, 95% confidence interval 2–4).The most frequent setting for BBF exposures among senior doctorswas the operating theatre/recovery (59%). Among junior doctors,it was the patient room (48%). The commonest original reasonfor use of sharps by junior doctors was the taking of bloodsamples (42%). Among senior doctors, it was suturing (41%). Conclusion While ongoing training efforts need to be directedtowards both junior and senior doctors, our data suggest thatjunior doctors are at higher risk of BBF exposures and may needparticular attention in prevention strategies. An improvementin the safety culture in teaching hospitals can be expectedto reduce the number of BBF exposures.     

Psychological and occupational predictive factors for back pain among employees of a university hospital in southern Spain

OBJECTIVES: To identify the individual and occupational factors that are predictors for low back pain among the employees of a university hospital in southern Spain. METHODS: A transverse study was conducted in which the population used was the hospital employees who volunteered to participate. The information was obtained by using a questionnaire, which included demographic and anthropometric variables, habits, characteristics of the work done, and of any pain experienced. The mental health condition of subjects was measured using the GHQ-28, using a score of > or = 6 as the cut-off point. To study the variables associated with pain, crude odds ratios (ORs) were calculated (+/- 95% CI) and adjusted according to a logistic regression model. RESULTS: One thousand one hundred and four subjects participated in the study but only 890 of these completed the questionnaire in full (rate of response, 35.7% of total employees). The population studied was notable for the high proportion of women, for subjects > 41 years of age, and subjects who undertook little or no physical exercise. In addition, according to the GHQ-28 test, 29.9% of the total were 'probable psychiatric cases'. The crude ORs were high in all the occupational categories in comparison with the doctors, with the exception of the maintenance, cleaning, and catering group. They were also higher among women, among subjects with poor mental health, and among women with one or more children. The adjusted ORs showed that having a GHQ-28 score of > or = 6, and belonging to the auxiliary technician category, were independent risk factors for suffering low back pain. Being older than 41 years and in temporary employment were protective variables. CONCLUSIONS: The presence of probable mental illness is the variable most strongly associated with the presence of low back pain in the population studied. Its diagnostic confirmation and appropriate treatment could contribute to reducing the prevalence of vertebral pains in this occupational group.     

A survey of trainees and recently accredited specialists in occupational medicine in the United Kingdom

Information from a study group of doctors training or recentlytrained in occupational medicine was gathered using a self-administeredquestionnaire mailed to each subject's registered address. Ofthe 224 individuals identified from scrutiny of records heldby the Faculty of Occupational Medicine, replies were receivedfrom 181 (81 per cent). Recruitment occurs in broadly equalproportions from general practice, general practice trainees,the hospital sector and the forces, with a wide diversity ofexperience among trainees. On average, trainees experience atleast two industrial sectors during their training. There weredisappointingly small numbers in part-time training.     

Risk perception and attitudes towards HIV in Serbian health care workers

BACKGROUND: Health care workers (HCWs) are at risk of occupational exposure to human immunodeficiency virus (HIV). AIM: To investigate the perception of professional risk from, and the knowledge, attitudes and practice of HCWs to HIV and AIDS in Serbia. METHODS: Cross-sectional study of 1,559 Serbian HCWs using self-administered anonymous questionnaires. Chi-square testing and multiple logistic regression analysis were applied. RESULTS: Eighty-nine per cent of HCWs believed that they were at risk of acquiring HIV through occupational exposure. The perception of professional risk was higher among HCWs frequently exposed to patients' blood and body fluids (OR 7.9, 95% CI 4.4-14.5), who used additional personal protection if the HIV status of patient was known (OR 2.6, 95% CI 1.5-4.6), who had experienced sharp injuries within the last year (OR 1.9, 95% CI 1.0-3.8) or who had been tested for HIV (OR 2.1, 95% CI 1.2-3.5), and among HCWs who had treated HIV-positive patients (OR 1.7, 95% CI 1.1-2.8). The majority of respondents had deficient knowledge about modes of HIV transmission. Attitudes towards HIV-positive patients were significantly different by occupation. Seventy per cent of HCWs used appropriate protection during their daily work with patients. CONCLUSIONS: HCWs require specific educational programmes and training protocols to ensure that they are adequately protected when carrying out high quality care.     

The general practitioners' view

General practitioners have patients on their lists who work in a variety of occupations, but the doctor is most unlikely to have had any training in occupational medicine. As a result, occupational causes for illness are rarely considered by GPs. Little contact occurs between occupational health physicians and GPs leading to a lack of understanding of the occupational physician's role. These two factors, when combined, may lead to patients receiving sub-optimal treatment. This could be remedied by better undergraduate and postgraduate training, and by greater professional contact.     

Back pain in pre-registration house officers

Back pain is a major burden on the working population. It is a particular problem amongst hospital staff, especially nurses. It has been poorly studied amongst doctors. Pre-registration house officers (PRHOs) starting their careers are exposed to a number of risk factors for back problems, both physical and psychological. This questionnaire-based study investigated the prevalence of back pain and its impact on the work of new graduates from two UK medical schools. Around half of the newly qualified PRHOs had significant back pain, one-quarter at least once a week. The frequency of back pain doubled once they started work, although the overall prevalence remained static. One in 10 of them had been unable to perform their normal work activities at some stage because of back pain. One in eight had sought professional help for back problems in the previous 5 years. Fewer than 50% of newly qualified doctors could recall any formal training in lifting and handling.     

Compliance with follow-up after occupational exposure to hepatitis C

BACKGROUND: Accidental percutaneous exposure to blood containing hepatitis C virus (HCV) is reported by health care workers more frequently than exposure to human immunodeficiency and hepatitis B virus. The transmission rate following such an exposure is approximately 1.9%. Little is known about the attendance rate of such staff for follow-up testing following exposure to HCV. AIM: To determine whether our follow-up programme for staff exposed to hepatitis C would allow the early detection and treatment of infected staff members. METHOD: We reviewed all staff exposures to hepatitis C reported to the occupational health department of a London teaching hospital over a 8-year period. RESULTS: Of 105 exposures, 21% of staff attended for early (6 or 12 weeks) and late (26 weeks) post-exposure follow-up. Thirty-seven per cent attended early follow-up only and 1% attended late having not attended early follow-up. Forty per cent did not attend any follow-up appointments with us. CONCLUSION: With the availability of effective treatment for early HCV infection, it is vital that occupational health departments encourage staff to attend at least for early follow-up. Access to HCV-RNA testing at this early stage should allow detection and early treatment of the small proportion who seroconvert.     

CPD for GPs using the THOR-GP website

BACKGROUND: An estimated 3200 UK general practitioners (GPs) practise occupational medicine on a sessional basis. AIM: To assess the educational needs of GPs practising occupational medicine and participating in The Health and Occupational Reporting (THOR) network. METHODS: A questionnaire survey of GPs participating in a national reporting scheme, recording occupational ill-health from general practice (THOR-GP). The questionnaire used scales derived from the syllabus for the Diploma of the Faculty of Occupational Medicine to assess the use of the THOR-GP website for continuing professional development (CPD). Questions were also asked concerning the attitudes and experience of these doctors to CPD in occupational medicine. RESULTS: The response rate was 73% (213/291). Only 22% of responders used the THOR-GP website for CPD. Lack of time was the most frequently cited reason for not using the site. The topics provided on the website which were rated least interesting also appeared as requests for further information in questionnaire returns. CONCLUSION: Online learning has the potential to fulfil the needs of GPs practising occupational medicine. The designers of material for online learning should actively manage and modify the material available in response to educational needs. Further research is required into the clinical and business outcomes of online learning for these doctors.