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.     

Market oriented occupational medicine

The history and the recent state of occupational medicine in Hungary, and its relation with governmental labor organizations are analyzed. In the past 20 years, large "socialist" factories were replaced by smaller companies employing fewer workers. They have been forced to establish contract with occupational health providers. Many of them offer primary care services, whereas family physicians having a board examination in occupational medicine are allowed to work in this field as well. The market of occupational medicine is less regulated, and ethical rules are not always considered. Undercutting prices is a common practice. The recent system could be improved by some regulations which should be respected. There is no reason to make rough changes establishing a new market for profit oriented insurance companies, and to allow employees and employers to work without specification neglecting international agreements. Occupational medicine should be supervised again by the health authorities instead of economists who have quite different, short-term priorities.     

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.     

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.     

The occupational medicine consultant

The occupational medicine consultant emerged in a few areas of the country during the 1940s. The concept is growing in popularity, with some recent evidence indicating that it may be the dominant career path for residency trained specialists in occupational medicine. The services provided to industry, labor, and government do not appear to compete with traditional occupational medicine positions. The manpower shortage in occupational physicians promises to fuel the growth opportunity for occupational medicine consultants. The major concerns at this time are the adequacy of liability insurance carried by the consultants and the possibility that their activities will too often be related to crisis situations rather than to the development of preventive medical programs with their clients.     

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.

     

Chronologic history of occupational medicine

OBJECTIVES: To provide a chronologic review of growing knowledge in occupational medicine relating work and work hazards to health, and to provide a perspective on the lessons learned from the frequent inattention or misrepresentation of hazards. METHODS: Many books on the social and medical history of work including epidemiology and toxicology were reviewed, as well as published papers and interviews. RESULTS: Throughout history workplace hazards and occupational medicine have been shaped by the forces that shape work itself, social evolution, changing modes of production, shifting economic powers, and demographic changes in the workforce. Lest we think these changes are unique to the present time, this paper emphasizes the long-term and inevitable relationship between social structure and worker health. Hippocrates emphasized the relation between environment (air and water) and health, although he has less to say about the non-military work environment, perhaps because of the denigration of manual labor in Greece. The impact of work on health can be traced to the Edwin Smith Surgical Papyrus, written approximately 1700 BC. The earliest occupational physicians served military forces, and Galen was physician to Roman gladiators. Finger and wrist guards worn by Bronze Age archers represent early personal protective equipment. Writers of the classic period mention diseases and hazards of miners, and Pliny (1st century AD) mentions veils to cover the face. In the Middle East Rhazes included occupation in his case studies (9th century). Paracelsus, and Agricola were prominent, figures in the 15th century, with an emphasis on mining and health. Ramazzini's (c1700) work was widely translated in ensuing decades and is now well-known to all, but its influence between about 1800 and 1940 is inapparent. The emergence of a public health movement in the mid-1800s focused attention on the abominable conditions of many factories and on the living conditions, poor nutrition, high stress, poverty and ill health of the new factory working class, while paying scant attention to specific workplace hazards. CONCLUSIONS: The recognition of occupational diseases in the United States has often lagged by a generation behind the recognition of the same diseases in Europe. We are now into a second industrial revolution led by multinational corporations and information technology, shifting production facilities, and jobs moving around the world in search of cheap labor in the countries with the fastest growing population and the greatest poverty. Occupational medicine must be alert to the new challenges imposed by this revolution.     

职业卫生与职业医学的发展趋势

职业卫生与职业医学是研究劳动条件对劳动者健康的影响以及研究改善劳动条件,创造安全、卫生、高效的作业环境,提高劳动者的职业生活质量的一门预防医学学科,职业卫生与职业医学的首要任务则是识别、评价和控制不良的劳动条件,以保护劳动者的身体健康;其次是对职业性病损的受罹者进行早期检测、诊断和处理,促使其尽早康复。 我国的职业卫生工作始于新中国成立之后,在全国科技工