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INTRODUCTION
Public concern over potential hazards to health from
exposure to chemical and physical agents in the
environment has increased remarkably in recent years.
Moreover, concern is widespread that the health care
system in the United States is unable to respond
adequately to the perceived or actual consequences of
toxic occupational and environmental exposures. To
address those issues, the Institute of Medicine (NOM) of
the National Academy of Sciences convened a committee
in 1987 to examine the rote of the primary care physician
in occupational and environmental medicine and to offer
recommendations to foster physician involvement in
occupational and environmental health.
In its report, The Role of the Primary Care Physician in
Occupationa/ and Environmenta/ Medicine, ~ the fOM
committee identified three specific problems:
· a shortage of specially-trained physicians to
serve as teachers, researchers, and
consultants to practicing physicians;
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.
a lack of readily accessible information on
toxic substances in the workplace and the
general environment; and
· barriers in medical education and clinical
practice that limit physician involvement in the
area, inclucling the perception that
occupational and environmental health
conditions are infrequent, difficult, and
time-consuming to diagnose and treat; the
existence of significant economic
disincentives such as the fragmented and
often adversarial workers' compensation
insurance system; and the pervasive
presence of complex ethical and legal issues.
The lOM committee recommended that "ail primary
care physicians be able to iclentify possible occupationally
or environmentally induced conditions and make
appropriate referrals for follow-up". ~ To achieve that
minimum standard of care, the committee concluded that
all physicians must know some basic principles of
occupational and environmental medicine, know how to
take. an appropriate occupational and environmental
history, understand the physician's role in the major
workers' compensation systems, be aware of the ethical,
social, and legal implications of the diagnosis of these
conditions, and know when and how to report hazards to
public health and regulatory authorities.
In 1988 the lOM convened a new committee to assign
priorities and develop specific strategies for implementing
the first commidee's recommendations. A subcommittee
was formed to address the physician specialist shortage
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and the concomitant deficiencies in undergraduate and
graduate medical education. This report is based on the
deliberations of that subcommittee. It includes
observations of participants at a workshop convened by
the subcommittee in 1989 and amended by specialists in
internal medicine, family practice, pediatrics, and
occupational and environmental medicine, as well as by
representatives from government agencies and private
foundations. It makes a series of specific strategic
recommenclations for alleviating the physician shortage in
occupational and environmental medicine.
For the purposes of this recort. the following
-
· . . , _
definitions of occupational and environmental medicine
(OEM) were employecl. Occupational medicine is at'
aspects of the relation between workplace factors
(including physical, chemical, biological, social, and
psychological) and health, with emphasis on the effects of
work on health. Environmental medicine incorporates
most but not all aspects of occupational medicine, and
encompasses conditions caused or aggravatecl by
exposure to (~) toxic chemical substances, such as
formaldehyde and asbestos, that are either man-made or
become biologically available as a result of human
activities; (2) physical agents, such as radiation or noise,
that occur naturally or as result of human activities; and
(3) biological substances, such as LegionelIa spp. in
heating and ventilation systems, that become problems as
a result of human activities. 2 The domain of
environmental medicine also includes the psychological
burden of anxiety and concern about environmental
*A second subcommittee on information systems was
formed to address the issue of Meeting Physicians' Neec/s
for Mec/ica/ /nformation on Occupations and Environments
(/nstitute of Medicine, 79909.
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hazards--concerns that in some cases outweigh the direct
biological threat. Environmental medicine excludes health
effects of such behavior as active cigarette smoking, but
includes exposure to a wide range of non-occupational
physical, chemical, and biological factors (Figure 1~.
Figure 1. Confluence of Occupational and Environmental
Medicine
ENVIRONMENTAL /
MEDICINE ~
/~
-
Occupational Medicine:
\ OCCUPATIONAL
~ MEDICINE
V
All aspects of relation between workplace
factors and health.
Environmental Medicine: Effects on health from exposure to physical agents
and toxic chemical and biologic substances which may
be natural or result from human activities.
Representative terms from entire chapter:
physician involvement
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