Special Series: Where Have We Been, and Where Are We Going?

Has corporate influence limited occ-med docs?

Most docs unable to advocate on behalf of workers

(Editor’s note: Our cover story this month is the first in a two-part series on the field of occupational health. In this first article, we will discuss a controversial article published in the American Journal of Preventive Medicine that paints a bleak picture of the industry, attributing current failures to practitioners. In next month’s cover story, we will take a look at the prospects for the future of the profession and the megatrends that will help shape that future. As always, we are anxious to hear from you. E-mail us at alison.allen@ahcpub.com to let us know how you feel about the comments your colleagues make on our pages and the challenges you are facing in your own professional endeavors.)

With an ominously titled treatise on the fate of occupational medicine, a physician at the University of California, San Francisco (UCSF) School of Medicine has engendered a flood of comments in electronic communities across the country. "The Rise and Fall of Occupational Medicine in the United States,"1 published in the April issue of the American Journal of Preventive Medicine, asserts, among other things, that:

  • "Industry money and influence pervade every aspect of occupational medicine"
  • "In this financially charged environment, it is difficult to find an occupational physician with the temerity to speak out on behalf of workers."

The author, Joseph LaDou, MD, of UCSF’s division of occupational and environmental medicine, paints a picture of a profession that experienced rising hopes in the 1970s as governmental agencies sought to transform occupational medicine into a major clinical specialty, but now must deal with the reality of a promise unfulfilled.

Among LaDou’s other claims:

  • "For the most part, occupational physicians . . . are not coming together to plan a future for a specialty that is failing to thrive."
  • The other occupational health team members generally consider the occupational physician the most expendable member of the team.
  • Occupational health nurses are gradually taking over industry positions formerly held by occupational physicians.
  • The small number of new board-certified specialists (fewer than 100 a year) "is far below that which would be required merely to replace the loss by retirement of older board-certified physicians."

Whether they agree or disagree with the key points LaDou makes in his paper, occupational health professionals say the dialogue inspired by its publication is good for the profession. "He has definitely raised the flag on some important issues," says Deborah V. DiBenedetto, president of the Atlanta-based American Association of Occupational Health Nurses (AAOHN). "It’s a good, thought-provoking article. It opens up the opportunity for dialogue and demonstrates that we can develop a common voice on how to go forward." As to her own thoughts on LaDou’s paper, DiBenedetto notes that "there are kernels of truth in what he says, but he has taken his points to the extreme."

William B. Patterson, MD, MPH, FACOEM, chair, medical policy board at OH+R, Hingham, MA, agrees with DiBenedetto that "it is absolutely healthy in general for us to have this dialogue." Upon reviewing several e-mails to electronic communities in which he participates, Patterson notes "there were some occupational health nurses who felt he was too negative, others who felt his predictions of the demise of occupational medicine were premature and that new avenues will open up."

A mixed reaction

Patterson’s reactions to LaDou’s claims that occupational health is dominated by corporate America are decidedly mixed. "My first reaction is that he is absolutely correct that the number of physicians working for corporations has dropped dramatically. Everybody knows that," he says.

However, he adds, "From a specialty point of view, that is potentially good. What that means is that practicing occupational physicians are less dependent than they used to be on one employer. I think he is quite correct to point out that since corporations control the vast majority of the money spent in occupational medicine, there is a tremendous pressure upon practicing occupational health professionals to work cooperatively with corporations."

Patterson adds that the substantial majority of corporations with whom he has worked have been interested first in quality medical care and second in an honest opinion. "If I give an employer an honest opinion that will stand up to scrutiny, I’m doing them a favor," he asserts. "If I give them a slanted opinion that could be overturned by a physician advocating for the employee, I’m not doing them any favors."

This is not to say that some corporations don’t exert undo pressure on occupational health professionals. In his article, LaDou cites the example of David Kern, MD, an occupational physician at Brown University and physician at The Memorial Hospital, both in Providence, RI. Kern investigated interstitial lung disease occurring in nylon flockers at Microfibres, a Pawtucket, RI-based multinational corporation. Microfibres and hospital administrators tried to block Brown’s presentation of his findings in 1997, but he continued his efforts and brought NIOSH into the investigation.

Although he ultimately received a Health Achievement award from the American College of Occupational and Environmental Medicine (ACOEM), Kern was relieved of his position as head of the Brown occupational medicine program, the clinic was closed and he was ultimately dismissed.

"Yes, there are clients like Microfibres," says Patterson. "There are unfortunately individual managers in some companies who exploit workers or explicitly seek opinions favorable to the employer. My own approach, and what I recommend for our company’s providers, is to stick with your own opinion. If it becomes intolerable, you need to refuse to provide services to that client."

Seeking compliant providers?

There are some areas of the discussion of corporate domination where Patterson parts company with LaDou. "I disagree with him when he says industry will continue to hire the most compliant and most cost-effective health care providers," he says. "I say it’s reasonable to hire cost-effective practitioners who provide good care and get employees back to work quickly. I would distinguish between corporate relationships and compliant relationships."

DiBenedetto concedes that the tendency for companies to look for the most cost-effective providers has helped occupational health nurses and hurt physicians, at least in the workplace. "A nurse with the right training and experience can play a different role, for a better price and be more cost-effective, but will also know when to call in a physician," she explains.

Nurses are replacing doctors, but providing a different service — not as clinicians but as occupational health professionals, she continues. "We can do absolutely everything a physician can do except practice medicine. With the outsourcing of a lot of services, you don’t need the clinician in-house. Companies are looking more for a practitioner with the management and business skills to manage programs."

Which gets us back to cost-effectiveness. "Doctors and nurses are in the business of providing hands-on care. All of us are advocates for patient and safety welfare," DiBenedetto says. "Businesses recognize it’s to their advantage to keep employees healthy and productive, but they don’t want to hear the bleeding-heart side of things. They want to see cause and effect, return on investment, and [its linkage to] keeping employees productive, healthy, and on the job."

Occupational health professionals have to advocate for patients appropriately and based on a business perspective, DiBenedetto continues. "You have to speak the language of business so that the corporations understand and see the value of what you are doing," she observes. "Sure, we don’t want anyone hurt, but how do you quantify that? How do you avoid the increased cost of health and safety risks? Of absenteeism? We can definitely advocate for health and safety by showing the cost-benefit of putting in our programs."

But even a strong business case may not be enough, says Patterson. What might really be needed is an attitude adjustment on the part of corporate leaders. "One thing that bothers me is that occupational physicians ought to be more vocal in calling for training in ethical standards for corporate leaders, businessmen, and managers," says Patterson. "Probably the best example is ergonomics," he continues. "Employers have resisted standards from OSHA, despite the fact that ergonomics programs have proven to be cost effective."

Employers, he explains, often measure manager effectiveness by the number of recordable injuries that occur in the workplace. "Sometimes, pressure is put on docs to withhold prescription-strength anti-inflammatories so the event will not be OSHA-recordable. Or, they may assign people to restricted duty, which is recordable, without recording it. This is an example of a poor corporate practice that occupational physicians should be vocal about. They should be seeking more training of safety managers and human resource managers in this area. They have an ethical duty," Patterson asserts.

Changes in the wind

Patterson takes issue with LaDou’s charge that physicians are not coming together to ensure a better future. "ACOEM has made tremendous strides in the last five or six years," he says. "They have reached out to government and encouraged physicians to lobby and organize." He notes that there were "some administrative difficulties" at ACOEM that hurt its ability to take some actions it should have, but that these have been resolved.

Still, notes DiBenedetto, who joined ACOEM this year, 80% of the organization’s membership consisted of corporate physicians. That number now is only 15%-20%. "And fewer than that are full-time occ-med docs," she says. One positive sign, she notes, is a growing number of occupational health physicians going back to school to get their MBAs. "As nurses and physicians, we don’t receive basic business skills as part of our professional training," she explains. "More and more docs are now looking at how to apply business knowledge within their practices. This will put them in a better position to advocate for their patients."

Patterson agrees. "To the degree that physicians use their education to advocate for effective health and safety measures, that’s a positive," he says. He’s in accord with LaDou on another key strategy for strengthening the profession. "I completely agree with him in his support for alternative pathways for board certification," he says. "With the closing of occ-med residencies and a continued attraction of occupational medicine for mid-career physicians, the alternative pathways should be strengthened, not weakened. I think there will be a continued interest in occupational medicine by experienced family practitioners and emergency physicians who are looking for a change of lifestyle. Many come from strong clinical and good educational backgrounds, and there should be a way for them to become board-certified."

Many hospitals have such programs, he notes, "and for our part, we prefer to hire those physicians with formal [occupational medicine] training."

DiBenedetto sees an ongoing challenge for both occupational health nurses and physicians, noting that doctors and nurses both face marketplace challenges. "When I think of the shift of the marketplace, yes, physicians have definitely lost out [in terms of corporate positions], but we have, too, because we perform staff functions," she says. "It’s more a result of the baby boomers deciding to do other things with their lives."

Finally, notes Patterson, some things are simply out of the hands of occupational health professionals. "Occupational medicine — more than any other specialty — is sensitive to the winds of political change," he observes. "For example, the current emphasis on bioterrorism is good for occupational medicine, but if we don’t have a government that’s supportive, we won’t have support for research and residencies. Unfortunately, occupational medicine represents working people who lack political power, and you often get less support in Washington, DC, and in the state houses for common occupational injuries and illnesses than you do for rare cancers and rare diseases."

Reference

1. LaDou J. The rise and fall of occupational medicine in the United States. Am J Prev Med 2002; 22(4):285-295.

[For more information, contact:

William B. Patterson, MD, MPH, FACOEM, Chair, Medical Policy Board, OH+R, 175 Concord St., Suite 36, Hingham, MA 02403. Telephone: (781) 741-5175, ext. 234. Fax: (781) 741-5499. E-mail: bpatterson@ohplus.com.

Deborah V. DiBenedetto, MBA, RN, COHN-S, ABDA, American Association of Occupational Health Nurses, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. Telephone: (770) 455-7757. Fax: (770) 455-7271. Web site: www.aaohn.org.]