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AAMC Reporter: April 2007Viewpoint:
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Occupational and environmental medicine (OEM) is unique. Our practice is driven by the economy and technology, not new drugs and devices.We blend population health management with individual patient care and have always done so.We have an active research community, but much of our daily work lies outside clinical practice. We have no inpatients and little presence in hospitals. We are almost invisible to the rest of medicine.
Our practices and positions are highly individualized and varied.We provide acute care for work-related injuries and illness but also chronic disease management, medicolegal services, environmental medicine, health promotion and disease prevention, and services in a number of "niche" areas such as drug testing, "independent medical evaluations," and commercial driver evaluations. Workers' compensation is both the framework within which we manage and prevent disability and the major payment mechanism in our world.
OEM has a remarkably robust research infrastructure. The Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health conducts important intramural research, supports research through extramural grants, and sponsors a network of 16 education and research centers.
Although approximately 15,000 physicians practice OEM in the United States, only 3,000 practicing physicians are currently boarded in "occupational medicine" (the name recognized since 1955 by the American Board of Preventive Medicine), with approximately 70 new entrants each year. Board eligibility requires a minimum of one year of clinical training (virtually all programs require three years prior to entry, however), one year of didactic instruction leading to the master's of public health degree or equivalent, and one year of supervised practicum experience in occupational health settings.
We are severely constrained by the insufficient number and relatively small size of our training programs.Most new practitioners enter the field in midcareer as seasoned, mature clinicians already boarded in internal, family, or emergency medicine. Most cannot afford to take time off for additional specialty training, which is why there is about a 1-to-5 ratio between boarded and nonboard-certified OEM practitioners.
OEM leads in the occupational dimension of patient management, but we wish we could engage the rest of medicine in a discussion about what this means. Little physicians do affects the lives of workers and their families more than when we certify them as fit to return to work, achieve a good outcome for a work-related injury, or prevent an avoidable disability. Even so, OEM is virtually absent from the medical curriculum, and our lack of inpatients, makes us almost invisible to medical students, residents, and fellows. If we could say only one thing to medical students, it would be: Learn to take an occupational history! We would say to primary care practitioners: Learn to manage back pain effectively! We would say to specialty practitioners: Take certification of return to work as a serious medical commitment, not an afterthought, and describe disability in functional, not diagnostic, terms!
OEM does a great, unrecognized service to medicine as a first line of defense against questionable practice. Our role is frequently to explain patiently, to review the evidence, to say no, and sometimes to take abuse.We are a frequent target of activists who disagree with evidence-based medicine on issues such as multiple chemical sensitivity, dental amalgam disease, and toxic mold.
We are very conscious of our history. OEM as a medical field began with the publication in 1700 of Bernardino Ramazzini's masterpiece, De morbis artificum ("On the Diseases of Workers"). Alice Hamilton, who pioneered effective regulation, and Harry Mock, an early enlightened corporate medical director, were giants in our field in the early 1900s. During the 1950s, we were caught in the backlash against so-called socialized medicine, which at the time included any form of managed care, medical group practices, prepaid medical plans, and (ironically) corporate-based occupational health services. OEM naturally tends to swing through extreme cycles of growth and neglect. Our last big peak followed the Occupational Safety and Health Act of 1970 and extended into a "golden age" as exemplified by Irving Selikoff 's work on asbestos, followed by a rough patch after the 1980s when new positions and opportunities were scarce. We now seem to be enjoying a brisk upswing, at last.
Our future will depend on how we shape OEM in the modern world of employment and technology. The current ACOEM leaders have assertively redefined OEM physicians to be "public health professionals for the employed population," and have adopted as priorities excellence in health care (not least in workers' compensation practice), health and productivity (which also means a healthier worker living a better life), and worker and workforce protection. We have our challenges, of course. Our job prospects are newly bright, but our choked training pipeline will make it impossible to achieve our potential. Our specialty training programs and board certification requirements need a new, more modern model. It is essential that we assess and credential the competency of non-boarded practitioners who enter our field in midcareer. These challenges may be daunting, but OEM has shown remarkable endurance over the years.
Our future is ultimately secure because we are needed.
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