Workplace visits: an important place in family practice

Workplace visits: an important place in family practice

D.H. Cordes

The Institute of Medicine is concerned about the lack of trained occupational medicine specialists and believes that family physicians and other primary care physicians should have a role in the management of patients with work-related health problems.[1] A shortage of occupational medicine specialists clearly exists, and most of the patient care for occupational problems has become the responsibility of primary care physicians.[1] While many occupational medicine specialists do provide occupational health services to workers at the workplace, on-site physicians are found mainly in companies employing more than 500 persons, and 75 percent of employees in the United States work in companies that employ 100 people or fewer.[2]

Data from the Bureau of Labor Statistics on occupational illnesses and injuries in private industry[3] are the cause of the Institute of Medicine’s concern: workplace injuries and illnesses totaled 6.6 million in 1989, an increase of 136,000 over 1988. Of the nearly 6.3 million job-related injuries, almost one-half resulted in lost time or restricted work activities. Nearly 284,000 new cases of occupational illness occurred among workers in private industry.

The work-related medical problems of the 110 million workers in the United States are not usually treated by physicians specifically trained in the diagnosis and management of occupational illnesses. Workers who are employed by a company with no occupational health service frequently rely on their family physician for work-related health care.

To deliver comprehensive, well-informed health care to patients with possible work-related medical problems, family physicians should consider a visit to the workplace site to augment the office occupational history. Just as a visit to a patient’s home can help reveal the connection between environment and illness, the workplace visit, when carefully carried out, can be the foundation for the work history.[4] The workplace should be in question when considering disease etiology, and visits to the workplace can be made to gain information beyond what is learned in an office interview. Listening to the worker and taking a good history are not always enough.

By visiting the workplace, an understanding of the work environment can be gained, along with some conception of the effect it can have on the health of workers. Through visits to work sites, family physicians can become familiar with work processes and any attendant health threats to individual patients or to the community as a whole. Family physicians engaged by industry in providing occupational health services to employees will certainly want to conduct workplace visits for making management contacts and investigating any current plant concerns about work-related health problems.

Major physician organizations, such as the American Academy of Family Physicians, the American Medical Association and the American College of Physicians, have acknowledged the important connection between primary care specialties and the health of workers. The American College of Physicians has published a position paper on the internist’s role in occupational and environmental medicine.[5] The AMA has published a handbook on occupational health care for family physicians,[6] and AAFP offers a home study self-assessment monograph.[7]

In addition to these general resources, several recent occupational medicine manuals have chapters with specific instructions on how to arrange and conduct a workplace visit and carry out a risk assessment.[8,9] For study of specific occupational health problems and issues, the Journal of Occupational Medicine publishes periodic updates of a recommended resource library for occupational medicine.[10]

Another resource is the environmental health series from the Agency for Toxic Substances and Disease Registry (ATSDR). There are 26 self-study cases now available.[11] The case-study series, entitled “Case Studies in Environmental Medicine,” is available from Patricia Poindexter, M.P.H., C.H.E.S., ATSDR (E33), Division of Health Education, 1600 Clifton Rd., NE, Atlanta, GA 30333. From October 1992 to December 1993, American Family Physician published excerpts from 13 of the case studies in the ATSDR series.

The lack of occupational medicine consultants stems from the fact that most are employed in academics or by industry.[1] However, consultation about specific concerns will be available through the National Institute for Occupational Safety and Health (NIOSH). Contact national headquarters information services at 800-356-4674 for that information. There are also 14 NIOSH-sponsored Educational Resource Centers (ERC) in the United States. Individual centers can be contacted to obtain a list of courses and continuing education programs. The NIOSH office will have the name, address and telephone number of the ERC nearest you. To learn about specific hazards and exposures, ask to be put on the NIOSH publications mailing list. To receive a catalog and ordering information, contact the NIOSH publications department at 800-356-4674.

The National Library of Medicine offers a valuable occupational medicine resource for physicians and others in the form of access to Toxicology Data Network (TOXNET). This is a computerized system of files on toxicology and hazardous chemicals. Data otherwise difficult to retrieve about a broad range of chemicals include emergency medical treatment, safety and handling, exposure potential, regulatory requirements, carcinogenicity, and acute and chronic effects. For information about TOXNET, contact the National Library of Medicine, Specialized Information Services Division, 8600 Rockville Pike, Bethesda, MD 20894 (telephone: 800-638-8480). Local sources, such as a university, large medical center or poison control center, may also have access to data banks.

The literature has documented the success of workplace visits,[9,12] giving physicians increased insight into the health problems of individual patients and into the impact of work processes on the health of the family and on the community.

The U.S. Department of Health and Human Services, among its national health promotion and disease prevention objectives, includes 15 occupational safety and health objectives for reducing deaths, injuries and illnesses in the workplace.[13] Family physicians are in a position to help meet these objectives, and, through the workplace visit, can be in a better position to contribute to the important task of preventing, detecting and managing occupational disease and injury.

REFERENCES

[1.] Role of the primary care physician in occupational and environmental medicine. Washington, D.C.: National Academy Press, 1988. [2.] Pearson CE. The emerging role of the occupational physician in preventive medicine, health promotion and health education. J Occup Med 1980;22: 104-6. [3.] Survey of occupational injuries and illnesses, 1989. Washington, D.C.: Bureau of Labor Statistics. [4.] Larsen ME, Schuman SH, Hainer BL. Workplace observation: key to a meaningful office history. J Fam Pract 1983;16:1179-81,1184. [5.] American College of Physicians. Occupational and environmental medicine: the internist’s role. Ann Intern Med 1990;113:974-82. [6.] The role of the family physician in occupational health care. Chicago: American Medical Association, 1984. [7.] Jarvis JQ. Occupational medicine. Home Study Self-Assessment program. No. 137. Kansas City, Mo.: American Academy of Family Physicians, 1990. [8.] Felton JS. Occupational medical management: a guide to the organization and operation of in-plant occupational health services. Boston: Little, Brown, 1990. [9.] Guidotti TL, Cowell JW, Jamieson GG. Occupational health services: a practical approach. Chicago: American Medical Association, 1989:279-92. [10.] Committee Report. Recommended library for occupational physicians. J Occup Med 1991;33. [11.] Case studies in environmental medicine. Atlanta: Agency for Toxic Substances and Disease Registry, 1992. [12.] Mack H. Getting value from workplace visits. Occup Health 1985;37:314-7. [13.] Healthy People 2000: national health promotion and disease prevention objectives. Washington, D.C., Department of Health and Human Services, DHHS (PHS) no. 91-50213.

COPYRIGHT 1994 American Academy of Family Physicians

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