I recently had the opportunity to shadow a local occupational medicine physician over spring break. I arrived at his office Monday morning expecting a brief day of clinic, maybe some conversation over lunch; maybe I get lucky and he pays for my sandwich. Within minutes of meeting him, though, the physician offered to host me for the entire week on a “mini-rotation.”
“In all the years I’ve been giving that talk at the med school, I don’t think we’ve had a single student show interest until now,” he said while introducing me at the nurse station.
Like many schools, our curricular exposure to occupational medicine is minimal. We receive just one lecture dedicated to the specialty in the first two years, the talk to which the doctor was referring when he revealed the unified lack of interest. This is particularly relevant since he is the only provider in town, and every winter he extends an invitation to students to acquire more experience in the field. Of note, this is happening at a small medical program in a rural state where great emphasis is placed on primary care.
I accepted the offer, and although the specialty can vary significantly based on the workforce makeup of a particular region, I came away from five days in an occupational medicine practice with at least one nugget that generalizes to the specialty: occupational physicians (“occ docs”) are in a favorable position to catch people who might slip through the cracks in health care. Like a goaltender is in an auspicious place to act when shots inevitably make it past even a good defense, occupational physicians are sometimes neatly situated to help prevent or address illnesses in at-risk populations who would otherwise miss out on primary care. With this in mind, we can view occupational medicine as an opportunity to lower burgeoning health care costs and improve public health. Perhaps this idea will attract students who value these issues and are therefore considering careers in primary care.
So we ask, who are these “at-risk” populations? Among the industries most frequently utilizing occupational medicine services are manufacturing, service, transportation and construction. It should come as no surprise that such work environments can pose significant risk for on-the-job injuries and employee health. These are predominantly low-skill and manual labor workers, many of whom have spent, or will spend, decades making a living through physically demanding activity. During my mini-rotation, I noticed a theme regarding the patient demographic: male, young-adult, smoker and an ethnic minority (in disproportionately high numbers relative to the local population). We treated non-English speakers and performed several pre-employment physicals on men with a history of active duty military service. Along with female nurses who were in-house cases from the hospital, these occupational and demographic characteristics were quite typical.
“We don’t get a lot of CEOs in here,” the doctor said, referring to the stream of millwrights, fiberglass grinders and sugar beet and potato plant workers. A great deal of time was devoted to managing herniated discs and other low back injuries such as the one sustained by a middle-aged grocery stocker as she bent over to lift a turkey from the bottom of a freezer; or the one a Latino man suffered while going about the routine heavy lifting involved in ready-mix concrete manufacturing. It is worth noting here that musculoskeletal conditions, especially spine-related, are the most frequent chief complaints seen by occupational physicians. Also frequent are repetitive-use injuries such as ulnar and median neuropathies as well as de Quervain’s tenosynovitis, all of which afflicted the fiberglass grinders we saw in addition to the restrictive pulmonary disease they suffered from breathing in airborne particulates. On average, these sorts of work-related hazards are a greater concern to those of lower socioeconomic status than the college-educated or highly skilled. We are talking about people who may very well ruin their bodies doing the hard labor of society.
What about goaltending, then? How can occupational physicians use this unique access to a certain population for the purpose of preventing acute and chronic disease?
“We see a lot of these tough-minded guys,” he imparts. “They don’t go to the doctor. And they smoke, they drink way too much, they don’t exercise and some of them are working themselves to death on top of it. But if they get hurt at work, they have to come here. And maybe we find they’ve got high blood pressure, they’re pre-diabetic, we can talk about smoking, whatever it is. It won’t always mean they get the necessary follow-up when we’re done, especially if they don’t want it or just don’t have the means. But even if all we do is set them up with a good general doc, that’s a win.”
During my stay, we saw numerous people who had no primary clinician. We had the opportunity to discuss lifestyle factors related to health and wellness, to screen for depression and to address medical questions that had long been on patients’ minds but were only now being asked thanks to the sudden convenience of sitting face-to-face with a doctor. One gentleman appearing for a Department of Transportation physical paused at the end of the exam before asking about a suspicious skin lesion on his foot, which the occupational physician thought was most likely a dermatofibroma. However, since melanoma and carcinoma should be considered in the differential diagnosis, he set up an appointment with podiatry for further evaluation in case a biopsy was warranted. Sometimes being forced into a doctor’s office is just what a person needs.
This initiative is by no means new to those in the profession. The American College of Occupational and Environmental Medicine has a position statement titled Scope of Occupational and Environmental Health Programs and Practice, part of which outlines the importance of preventive medicine aimed at workers. However, the statement seems to focus on worksite wellness programs, which is another area of great potential that is currently lacking in implementation. Just as low socioeconomic status populations are more likely to work in hazardous occupations, they also show decreased rates of utilization of such health promotion programs compared to groups of higher socioeconomic status for various and complex reasons. This means workers with perhaps the most to gain from worksite wellness are in fact the least likely to receive its benefits. The efficacy of worksite wellness is now well-established, but more research into the utilization of these programs is needed, particularly studies that focus on underserved populations. In the meantime this further underscores the importance of occupational physicians as goaltenders, identifying patients who are likely to miss out on primary care and intervening when appropriate.
Interestingly, it is estimated that over half of occupational physicians are in a “late” or “senior” career stage, with only 17% in the early stage of their career. It seems apparent that health care and society at large could profit from an infusion of young talent that is passionate about this area, both in the clinical practice and research of disease prevention at the site of susceptible populations. This may be especially crucial when considering the cost of occupational disease. It is estimated that work-related injury and illness accounted for about $250 billion in medical and indirect costs in the US in 2007, similar to the total cost of cancer. Workers’ compensation covers only a portion of the total, so payment is transferred to taxpayers (Medicare and Social Security Disability), insurance policyholders, and the injured party through out-of-pocket expenses. If we care about curbing health care costs, we need to pay attention to the workplace and to preventive care.
It was an enlightening spring break, if not a relaxing or beach-filled one. We should remember the occupational physician as we try to craft a comprehensive primary health care delivery system, the achievement of which is becoming an increasingly important national objective particularly as we strive to improve health and not merely health care. Such a successful defense will need a skilled goaltender.