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OCR for page 17
17
STRATEGIES TO ADDRESS THE PHYSICIAN
SHORTAGE
There is a critical shortage of specialty-trained OEM
physicians in communities, in academic medical centers,
and in public health and related agencies. A severe
shortage of front-line primary care physicians who are
willing and able to care for patients with occupationa~y-
and environmenta~y-re~ated illness also exists.
To acldress
these shortages, highest priority must be given to
interventions that will increase the number of academic
OEM specialists who are needed to train sufficient
numbers of specialists and primary care physicians to
care for a large and currently inadequately served
population. The lOM subcommittee recommended the
following strategies.
Increase Interest in the Field
The physician shortage in OEM cannot be addressed
merely with interventions to increase the training and
availability of specialists. An important component of the
OCR for page 18
18
shortage must be recognized and addressed: insufficient
efforts are not undertaken to enhance the attractiveness of
OEM as a career option. Although the development of
numbers of interested applicants to some training
programs, a phenomenon that could worsen if further
strong role models in OEM will likely be accomplished by
increased training and availability of specialists, it is
important that undergraduate and graduate medical
trainees be exposed to OEM material. Fundamental OEM
concepts should be repeatedly introduced throughout the
pre-clinical and clinical years. For example, a validated
OEM screening history should be routinely taught in
courses about interviewing patients and a clear set of
learning objectives in environmental health should be
developed for the undergraduate curriculum. Strategies to
remove the many economic, legal, and ethical
disincentives to the practice of OEM, outlined in the initial
lOM reporY, should be implemented. At the same time,
national education efforts--by both the tederai government
and medical schools--should be made to increase
awareness about OEM and delineate the professional
opportunities in this expanding field.
.
Establish Centers of Excellence
The specialty of occupational and environmental
medicine is developing during times of limited financial
resources and with only a few academic programs
currently able to bridge the public health and the clinical
aspects of the field. A limited number of centers of
excellence--10 to 15--that provide specializecl training and
OCR for page 19
19
research in occupational and environmental medicine
should be established in the near future. They could
make the most of scarce resources and seize the
opportunity to create a critical mass of qualified faculty,
ancillary personnel, and facilities to train future academic
faculty. By serving as foci for OEM training, such centers
could speed the subsequent diffusion of faculty to other
medical schools and residency training programs; a critical
factor in achieving the longer term objectives of
widespread occupational and environmental medicine
training at the undergraduate and graduate ~eve! and in
meeting overall physician manpower needs in the field.
A major objective of these centers is the training of
future teachers and leaders who are well grounded in the
clinical, research and teaching components of
occupational and environmental medicine. Each
specialized center for training and research should be able
to (~) develop a program that will attract students with
prior or planned attainment of sound clinical training in a
primary care specially (internal medicine, family practice,
or pediatrics) who are oriented to academic careers; (2)
maintain a productive research base to assure academic
visibility of its faculty and research training opportunities
for its students; and (3) provide training in the clinical care
of a wide range of patients with potential occupationa~ly-
or environmental~y-related exposures and conditions.
Funding of these centers will require additional federal
resources, some of which should be directed to support
necessary training and faculty components. There is also
potential for funding through partnerships among private
sector founclations, organizations, industries, and state
governments.
OCR for page 20
20
Integrate Environmental Medicine with Occupational
Medicine Training and Research Programs
As defined earlier in this report, environmental
medicine incorporates most but not all aspects of
occupational medicine and also includes the effects of
exposure to a broad range of physical, chemical, and
biological agents encountered in the environment outside
the workplace. There are at least three important
differences between the fields:
(~) different populations
are at risk, with environmental medicine covering all ages
in the population; (2) different levels of exposure and risk
exist, with environmental exposures invariably lower, less
welI-defined, and associated with a less welI-developed
scientific clata base; and (3) clifferent legal and social
attributes, e.g., different compensation mechanisms.
There are also important similarities between the two
fields. Both disciplines require the physician's skill in
being able to characterize exposure and subsequent risks
under varying degrees of uncertainty, and both rely on
physician knowlecige in several broad subject areas that
include toxicology, epidemiology, public health,
ergonomics, and, to some extent, engineering.
On the basis of these similarities, and the fact that it is
the limited number of occupational medicine specialists
who are usually called upon to address clinical
environmental medicine questions, the committee
recommends that the specialty of occupational medicine
be formally expanded to include environmental medicine.
Accordingly, efforts to deal with the physician shortage
should seek strategies to train specialists with clinical,
.
OCR for page 21
21
research, and teaching experience in both environmental
and occupational medicine.
In order for the two disciplines to advance together, it
will be necessary to modify existing didactic, clinical, and
research training of future specialists in OEM. Curriculum
in occupational medicine should be altered to draw case
material from environmental medicine. For example,
teaching industrial hygiene, the mainstay of exposure
control in occupational medicine, will need to encompass
a broader view of environmental control and technologies.
The experiences of practicing occupational medicine
physicians and industrial hygienists represent a valuable
resource for curriculum design.
Clinical training must also be expancled appreciably,
particularly in those occupational medicine training
programs that rely solely on workplace practice settings or
industrial medicine clinics as clinical training sites. The
clinical evaluation of patients with potential environmental
conditions is vastly different from the practice of
occupational medicine in these settings, which is largely
comprised of pre-employment examinations, fitness and
disability assessments, and the treatment of work-related
injuries. Occupational medicine programs that offer
training in diagnostic clinical evaluation of widely divergent
clinical problems are most ready to make the transition to
training in clinical environmental medicine. Indeed, many
of these programs have already begun to respond to the
demand from patients and physicians for this service.
Finally, as part of the evolution of expanding the
borders of occupational medicine to include environmental
medicine, faculty and trainee participation in environmental
OCR for page 22
22
medicine research must grow and become an integral part
of specialized centers for training and research.
Increase Funding for Faculty Development
More funding is needed to strengthen existing
academic occupational and environmental medicine
programs and to assure adequate start-up resources for
newly Rained faculty, particularly those engaged in
cleveloping new areas of scholarly inquiry in occupational
and environmental medicine. Career development awards
in other disciplines, such as those in preventive pulmonary
medicine and cardiology and the geriatric faculty
development academic award programs, can serve as
models for providing salary support and resources to
persons committed to assuming leadership positions in
occupational and environmental medicine in schools of
medicine. The appropriate federal agencies, including the
National Institute of Environmental Health Sciences
(NIEHS), the National Institute for Occupational Safety and
Health (NIOSH) and the Agency for Toxic Substances and
Disease Registry (ATSDR), should establish comparable
awards in occupational and environmental medicine. These
awards shouIcl be for physicians, both tenured and in
tenure tracks, for development of their expertise in
occupational and environmental medicine.
In the absence of ful~-fIedged OEM faculty specialists,
funding is also neecled to address, in the short term, the
initiation of training in occupational and environmental
medicine in primary care residency training programs.
Such funciing would allow academic faculty in primary care
OCR for page 23
23
specialties to gain special competence in occupational and
environmental medicine by participating in intensive
training (usually 6 months to ~ year) at an academic
center with demonstrated excellence in the field.
In its earlier report, the committee pointed out the
need for a strong research base to facilitate faculty
development and integration within the traditional medical
school context,. Time for OEM in the curriculum is not
obtainable and residency programs have little likelihood of
success without full-time faculty who can compete for
valuable course time through their success as faculty
members. Such success hinges on the usual criterion of
research productivity, and thus an increase in extramural
research support in OEM is of central importance to
manpower development -- as well as being needed to
protect the public against environmental and occupational
hazards.
Support Residency and Fellowship Training
Funding is not presently adequate to support
graduate training in occupational and environmental
medicine. Only about one-half of available training
positions have the necessary funding. Given the need to
expand the number of available and funded training
positions in OEM, a significant infusion of federal monies
is needed in a field that is almost exclusively an outpatient
specialty and generates relatively few patient care dollars.
In order to maximize the limitecl additional funds likely to
become available, support should be focused on those
programs most likely to train academic OEM specialists.
OCR for page 24
24
These training funds could be an important component of
funding of specialized centers for training and research.
Certification and Accreditation in Occupational and
Environmental Medicine
Occupational medicine as a specialty in the United
States has as its historic academic base an identity with
preventive medicine, medical school degree programs,
and schools of public health. Certification of individuals is
provided only by the American Board of Preventive
Medicine, and accreditation of training programs is
available through the ACGME's Residency Review
Committee for Preventive Medicine. Environmental
medicine is a fledgling fielcl with no certifying or
accreditation mechanism.
Only in the past decade has
occupational medicine begun to gain a presence as a
clinical discipline within medical schools. It was in this
context that the initial lOM committee proposed exploring
the possibility of offering certificates of Added
Qualifications by the American Board of internal Medicine
(ABiM) and the American Boarcl of Family Practice (ABFP)
to diplomates in internal medicine and family practice who
had advanced training or experience in OEM. The mode'
for such an approach was the ABIM and ABFP practice of
offering a certificate of Added Qualifications in the field of
Geriatric Medicine. The subcommittee recognizes that
implementing a similar program for OEM is not without
controversy. Nonetheless, we recommend this strategy as
an effective means to address the shortage of OEM
clinicians who are needed as practitioners, consultants,
and teachers, particularly in locations not readily served by
OCR for page 25
25
academic medical centers. This strategy has the potential
to increase interest in OEM among the large pool of
primary care specialists by offering a second certificate to
those board-certified specialists who participate in one
additional year of clinical OEM specially training. tt should
be explored by the appropriate boards, including the
American Board of Pediatrics (ABP), ABIM, ABFP and
ABPM.
The subcommittee also recommends an alternative
approach to certification of the fulI-fIedged OEM specialist,
a streamlinecl dual certification program by a primary care
specialty Boarcl (ABIM or ABFP) and by the American
Board of Preventive Medicine. This process has been
adopted by ABIM in three areas, with the American
Boards of Pecliatrics, Emergency Medicine, and Physical
Medicine and Rehabilitation. Figure 3 outlines two
pathways by which candidates would quality for
examination by both the ABIM and ABPM; the first is
currently available, and the second is an alternative
approach that couIcl shorten training with cooperation of
the respective Boards.
OCR for page 26
26
Figure 3. Pathways for Admission to Examinations In
Internal Medicine and Occupational Medicine
Current
1 1
R-1 IM
R-2 IM
Alternative Pathway 2
L
PGY- 1
R-3 IM
Academic Practicum Practice
Year - OM Year - OM Year - O
IM Exam
R-1 IMR-2 IM IM ~Academic
OM
OEM Clinic
PGY - 2
R = Residency Year
IM = Internal Medicine
PGY = Postgraduate Year
1
OM
Practice
Year - OM 1
IM Exam
OM
OEM= Occupational and Environmental Medicine
0M = Occupational Medicine
Practice year includes clinical practice, full time faculty, or research in
occupational medicine.
2 If Residency Review Committee Preventive Medicine accepts a continuing
weekly clinic in OEM throughout PGY 2-4.
3 Up to six months of internal medicine may be allocated to another discipline,
such as occupational medicine.
Representative terms from entire chapter:
occupational medicine
