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Suggested Citation:"Front Matter." Institute of Medicine. 1988. Role of the Primary Care Physician in Occupational and Environmental Medicine. Washington, DC: The National Academies Press. doi: 10.17226/9496.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Role of the Primp Care Physician in Occupabon~1 and Environments Medians

Not only in antiquity hut irz our own times also laws have been passed in well-ordered cities to secure good conditions for the workers; so it is only right that the art of medictrze should con~trz~rute its portion for the benefit and relief of those for whom the law has shown such foresight; indeed we ought to show peculiar zeal, though so far we have neglected to do so, in taking precautions for their safety, so that as far as possible they may work at their chosen calling without loss of health.

Role f the Primary Care Physician in Occupational and Environmental Medicine DIVISION OF HE'S PROMOTION AND DISEASE ~~ION INSTITUTE OF MEDICINE NATIONAL ACADEMYPRESS Washington, D.C. 19~38

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee appointed by the members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. The study was supported under contracts with the Environmental Protection Agency (Grant Nos. R813648~1 and R813648-01-0~; the National Institute for Occupational Safety and Health, Centers for Disease Control; the National Institute of Environmental Health Sciences, National Institutes of Health; and a grant from the Charles A. Dana Foundation Incorporated (OPVT~658- 001~. Additional support was provided by the National Research Council (NRC) Fund (ALOC- 8897-001 ), a pool of private, discretionary, nonfederal funds that is used to support a program of Academy-initiated studies of national issues in which science and technology figure significantly. The NRC Fund consists of contributions from a consortium of private foundations including the Carnegie Corporation of New York, the Charles E. Culpeper Foundation, the William and Flora Hewlett Foundation, and the John D. and Catherine T. MacArthur Foundation, the Andrew W. Mellon Foundation, the Rockefeller Foundation, and the Alfred P. Sloan Foundation; the Academy Industry Program, which seeks annual contributions from companies that are concerned with the health of United States science and technology and with public policy issues with technological content; and the National Academy of Sciences and the National Academy of Engineering endowments. Translated excerpts from De Morbis Dzatnba (Diseases of Workers) by Bernardino R:unazzini are reprinted in this report with the permission of the Classics of Medicine Library O1983 Special Edition copyright. A reprint ofthe Latin text ofthe 1713 revised edition, with translation end noses by Wilmer Cave Wright, published by the University of Chicago Press, 1940, copyright 1940, by the New York Academy of Medicine. Woodcuts from The Book of Trades (Standebuch) by lost Amman and Hans Sachs (New York: Dover Publications, 1973, with an Introduction by Benjamin A. Rifkin) are reprinted in this report with the permission ofthe publisher. The woodcutswere originally published in Frankfurt am Main in 1568. Publication No. IOM-88{)5 Available from: National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 A charge of $3. DO for postage and handling is required. Printed in the United States of America

coMMIrrEE ON THE ROLE OF THE PHYSICIAN IN OCCUPATIONALAND ENVIRONMENTAL MEDICINES Bernard D. Goldstein (Chair), Professor and Chairperson, Department of Environmental and Community Medicine, UMDN{/Robert Wood Johnson Medical School, Piscataway, New~ersey Joseph M. Cannella, Corporate Medical Director, Mobil Oil Company, New York, New York David S. Citron, Director of Medical Education, Charlotte Memorial Hospital and Medical Center, Charlotte, North Carolina Molly Joel Coye, State Commissioner of Health, New Jersey Department of Health, Trenton, New Jersey Neil I. Elgee, Clinical Professor of Medicine, Summit Madison Medical Group, Seattle, Washington Robert A. Fried, Luther L. Terry Preventive Medicine Fellow, Association of Teachers of Preventive Medicine, Washington, D.C. Peter B. Mutt, Partner, Covington and Burling, Washington, D.C. George W. Jackson, Director of Employee Occupational Health and Chief of the Division of Occupational Medicine, Duke University Medical Center, Durham, North Carolina Alan A. McLean, Clinical/Associate Professor, Department of Psychiatry, Cornell University Medical College, Westport, Connecticut Clifford S. Mitchell, Resident Physician, Department of Medicine, Francis Scott Key Medical Center, Baltimore, Maryland Linda Rosenstock, Director of Occupational Medicine, Universiny of Washington, Seattle, Washington James L. Weeks, Deputy Administrator for Occupational Health, United Mine Workers of America, Washington, D.C. David H. Wegman, Professor and Head, Department of Work Environmen. ~ College of Engineering, Lowell, Massachusetts Stanford Wessler, Associate Dean of Postgraduate Programs, New York University School of Medicine, New York, New York Consultant Kathleen M. Rest, Pew Health Policy Fellow, Boston University, Boston, Massachusetts *See Appendix B for further information on committee members and the consultant. v

Institute of Medians Stab James V. Warren, Study Director Enriqueta C. Bond, Director, Division of Health Promotion and Disease Prevention Kyung-Sook Lee, Research Associate Wallace K Waterfall, Editor Linda DePugh, Administrative Assistant Contributors of Commissioned Paperer Nicholas Ashford, Associate Professor of Technology and Poliq, Center for Technology, Policy, and Industrial Development, Massachusetts Institute of Technology, Cambridge, Massachusetts Edward Baker, Deputy Director, Centers for Disease Control/National Institute for Occupational Safepr and Health, Atlanta, Georgia Leslie I. Boden, Associate Professor of Public Health, Environmental Health Section, Boston University, Boston, Massachusetts Mark Cullen, Associate Professor, Medicine/Epidemiology, Yale Occupational Medicine Program, New Haven, Connecticut Ray Demers, Associate Professor, Wayne State University, Department of Family Medicine, Center for Occupational Health, University Health Center, Detroit, Michigan Frank Goldsmith, Dean, Harry Van Arsdale School of L abor Studies, Empire State College, State University of New York, New York, New York Warren Heffron, Professor and Chairman, Department of Family, Community and Emergenq Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico Patricia Honchar, Chief, Surveillance Coordinating Activity, Office of Director, Centers for Disease Control/National Institute for Occupational Safety and Health, Atlanta, Georgia Thomas Kottke, Assistant Professor, Department of Cardiology, University of Minnesota, Minneapolis, Minnesota Bany Kelly, Director, Occupational Health Program, Department of Family and Community Medicine, University of M~chusetts Medical Center, Worcester, Massachusetts Daniel Masys, Director, Lister Hill Center, National Library of Medicine, Bethesda, Maryland Raymond Neutra, Chief of Epidemiology, State of California Deparunent of Health Services, Berkeley, California *See Appendix A for abstracts of the commissioned papers. v'

David Parkinson, Chief of Occupational Medicine, Department of Community and Preventive Medicine, Health Science Center, State University of New York at Stony Brook, Stony Brook, New York Graham Ward, Assistant Research Professor of Medicine, The Cardiovascular Institute, Boston, Massachusetts Other Contributors Norbert I. Berberich, Chief, Curriculum Development Group, National Institute for Occupational Health and Safety, Cincinnati, Ohio Henry Falk, Director, Division of Environmental Hazards and Health Effects, Centers for Environmental Health and Injury Control, Centers for Disease Control, Atlanta, Georgia Barry Johnson, Associate Administrator, Agency for Toxic Substance and Disease Registry, Atlanta, Georgia Kathryn Kahler, National Correspondent for Newhouse Newspapers, Washington, D.C. Marvin Kuschner, Dean of the Medical School, Health Science Center, State University of New York at Stony Brook, Stony Brook, New York Frank Mitchell, Chief Medical Officer, Agency for Toxic Substance and Disease Registry, Atlanta, Georgia Anthony Robbins, Professor and Director of Vaccine Project, School of Public Health in the School of Medicine, Boston University, Boston, Massachusetts August Swanson, Vice President, Division of Academic Affairs, American Association of Medical Colleges, Washington, D.C. Ralph Yodaiken, Director of the Office of Occupational Medicine, Occupational Safety and Health Administration, Department of Labor, Washington, D.C. Sponsors ' Representatives Scott R. Baker, Special Assistant to the Assistant Administrator, Office of Research and Development, Environmental Protection Agency, Washington, D.C. Stephen Foster, Program Officer, The Charles A. Dana Foundation, New York, New York Carl Keller, Epidemiologist, National Institutes of Health, Bethesda, Maryland Max Lum, Health Educational Specialist, Agency for Toxic Substance and Disease Registry, Atlanta, Georgia Melvin L. Myers, Deputy Assistant Director, Centers for Disease Control/National Institute for Occupational Safety and Health, Atlanta, Georgia . . v::

Contents A Note, x Preface, xi Exe curve Summary, ~ CHAPTER ~Introduction: The Nature of the Study, 11 CHAPTER 2 The Cause for Concern: An Analysis of the Problem, 15 Incidence of Occupational and En~nronmentalI9isease /Euidence of Need and Less Than Optimal Physician Partiapation / Changing Scene of Medical Care / Inadequate Education / Lack of Medical School Faculb / Practicing Physicians' Attitudes Toward Health Promotion and Disease Prevention /Problems in Practice /EconomicIssues /Legal Issues /Ethical Issues /Fragmented Agency R~sponsibik~ CHARTER 3 GoalS and Inte~veni~ons for Clinical Practice, 29 Interventions / The Microen7nronment of Primary Care Office Practice / I?,format~n: What Is Needed ~ /Infor~nation: How to ~ It, / The Macroer~vimnment of Medical Pra=ce CHAPTER 4 Recommended Interventions in the Education of Future Physicians, 47 Educating Objectives for Ur~r~aduate Medical Education /Educa~ Objectives of Graduate MedlicalEducation /Ba~ to Tead ing Occupation and Environmental Medicine / Incenses for Teaching Occupational and Entnronmental Medicine /Intervention Strategies vial

CHA~rER ~Summary of Principal Recommendations, 63 Recommendations to Foster the Role of Primary Care Physicians in Presently Patient Care Activities / Recommendations Related to the Education of Future Physicians / General Recommendations CHAPTER 6 Concluding Remarks, References, 74 APPENDIX A Abstracts of Commissioned Papers, 78 The Role of the Primary Care Physician in Legal Aspects of Occupational Health / Surveillance of Occupational Disease: Strategies for Improving Physician Recognition and Sporting / Incentives to Diagnose, Treat, and Report Occupational and Environmental Disease / The Challenge of Teaching Occupational and Environmental Medicine in Internal Medicine Residencies / Curriculum Approaches to the Teaching of Occupational Medicine in Family Practice Residencies / Current Status and Trends in Reimbursement of Occupational Health Services for Wooers /AI~rzng Physicians ' Behavior Patterns and Skills Through Education /refining the Extent of Occupational Risk /Prevention and Detection of Occupationally Related Diseases by Primary Care Physicians: Developing the Paradigm / Occupational and Environmental Health Content of Internal Medicine and Family Medicine Journals / Improving Medical School Education in Occupational Health: What Should We Try to Do and How Should We Try to Do It' /New Information Technologiesfor Medical Practice / Changing Physician Behavior: A Sys~ms-Marketing Approach APPENDIX B Biographical Information on Committee Members and Consultants, 91 APPENDIX C Glossary, 95 ax

A Note The problems discussed in this volume are as universal and as old as work and the environment. For this reason we thought it appropriate to illustrate this new Institute of Medicine study with words and woodcuts that preciate it by several hundred years. The woodcuts are from a sixteenth-centu~ book publisher} in Germany. The words are from the Italian physician Bernardino Ramazzini, scholar and professor of medicine at the University of Padua, who wrote them in the seventeenth century and spent his life studying the problems of workers and the environments they inhabited. Although our quotations focus on occupation and its environment, we emphasize that the study and this report equally address more general concerns of the environment at large --in the home, on the street, as well as at work. The coupling of health and the environment is an ancient one that has left its mark on our language in such words as malaria ("bad air") . Even Hippocrates stressed environmental factors in disease in his writings On Airs, Waters, and Places. John Evelyn, a founder of the Royal Society, wrote of seventeenth-century London: "The inhabitants breathe nothing but an impure mist, accompanied with a fuliginous and filthy vapor which renders them obnoxious to a thousand inconveniences, corrupting the lungs, ancl disordering the entire habitat of their bodies, so that catarrhs, phthisics, coughs, and consumption rage more in this city than in the whole earth besides. " He could have been clescr~bing any number of today's cities. For their assistance to the committee in completing its task, we are grateful to Pamela Reznick and to Heather Wiley for the design and conception of this volume. James V. Warren, Study Director x

Preface One of the most persistent trencts in American society has been an insistence on the citizens' rights to be informed and to participate in all areas that affect their personal welfare. This has certainly been true in matters relating to health. With marked improvement in our overall health status and advances in our unclerstanding of the causes of illness, we have come to believe that we have a right to good health, as well as a right to an explanation of why poor health occurs. Among the external etiologic factors receiving particular attention in recent years have been the interrelation between work and health and the impact of chemical and physical agents in the workplace and general environment on well- being. We no longer accept injury and illness as inevitable consequences of occupation, nor do we quietly accept contamination of the general environment with chemicals. Indeed, the public outcry against such pollution parallels the concern that produced the Sanitary Revolution in the mid-nineteenth century. A relatively new dimension to the public's understanding of the potential threat of chemical and physical agents in the general environment or workplace has been the recognition that their effects on health can be insidious, developing only after decades of exposure. The nature of such effects, particularly cancer and reproductive damage, has further fueled public concern. This increasing recognition and the concomitant call for reductions in occupational and environmental risks have not been without controversy. Laws have been passed, federal agencies have been established, and literally billions of dollars have been spent to protect public health and the environment. These activities and expenditures have had a considerable impact on U.S. incrusts, as employers and producers. They have also affected the practice of medicine. Employers, workers, and individuals look increasingly to the health care system for information and advice about exposures and health risks, for cliagno- sis and treatment of diseases caused and exacerbated by toxic occupational and x~

environmental exposures, and for guidance about prevention. Medicine has evolved a boarded specialty in occupational medicine, and some occupational medicine specialists have provided leadership in the field. However, they are few in number. For these reasons, the Institute of Medicine convened a committee to offer suggestions on how to foster the role of the primary care physician in environ- mental and occupational medicine. The committee approached this topic with an appreciation of the increasing number of roles that primary care physicians are asked to assume. The committee also recognized the broad responsibilities and multiple demands that confront these hardworking individuals. Thus, the committee's approach was to define an ideal goal, and then to focus its recommendations on practical ways to integrate the necessary information and skills into existing practice and education patterns. The committee also recom- mended system changes to facilitate the ability of primary care practitioners to actively participate in occupational and environmental medicine. The committee's report contains a discussion of the extent to which occupa- tional and environmental factors affect the practice of primary care medicine. Precise estimates are impossible because incidence and prevalence data are inadequate. But, with the paucity of specialists, there is no question that diagnosis, treatment, and the opportunity for prevention in occupational and environmental medicine are part of the practice of primary care physicians to a greater or lesser extent. It is also likely that the role of primary care physicians in this area will continue to increase. More and more, the controversial aspects of environmental problems are being fought at the local level, so the public will likely turn to local community physicians with their exposure/health effect questions and for advice about trade-offs between health and other local issues, such as job loss. Similarly, the new workplace right-to-know laws, and the likely advent of community right-to-know laws, will convey more information about exposures to potential and adverse working conditions to workers and to the public The significance of this expanded information to the practice of medicine at the local level can be predicted. In identifying problems, the committee attempted to look to their root cause and make recommendations on that basis. For example, the committee felt that it was insufficient to simply state that the U.S. workers' compensation system is a deterrent to physician involvement without looking to the reasons and the ways in which the primary care physician's role in treating workers under this system could be facilitated. Similarly, the committee's recommendations to enhance and improve medical school curricula in occupational and environmental medicine were developed with the realization that faculty presence en c} a willingness and capability to teach such curricula are crucial to their success. The committee's recommendations are based on the existing structure of American medicine. Any overall change in this structure that wouIct enhance the . . x:'

role of the practicing physician as an agent for the prevention of disease and promotion of well-being would make the committee's goals more readily obtainable. The committee's efforts were greatly abetted by the many individuals listed above who contributed their expertise in the form of commissioned papers presented at a workshop in Woods Hole, Massachusettes, in July 1987. The abstracts of these presentations are included as Appendix A of this report. Our report would not have been possible without the dedicated efforts of the staff, particularly James V. Warren and the consultant to the committee, ELathieen Rest. B. D. Goldstein, Chair xaaa

~! ~ _ === ~ AJAR JI0~ - ~ 'a it?, ~ _ · ~ At' . ._ . ~- `~ ever Hi' s \_ Various arid manifok] is the harvest of diseases reaped by Cain workers from the crafts and tradLes that; they pursue; all the profit that they get is fatal injury to their health.

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