Occupational and Environmental Medicine: Public Health and Medicine in the Workplace

Occupational medicine is unique in medicine because it focuses on the interface of the workplace and health. Occupational medicine physicians combine individual patient care with prevention and a population-based health approach and may be engaged in all aspects of workers’ health and the workplace. They may spend more time addressing issues in healthy workers, workers’ groups, employers, or companies because only 45% of their time is used to address injured or ill patient issues.¹ Important occupational health issues that need to be addressed worldwide include working conditions; the built environment; and chemical, biological, physical, and psychosocial hazards.² Today, the specialty encompasses workers’ wellness, disease prevention, and environmental issues in addition to occupational injury and illness care.

HISTORY

Even before becoming one of the three preventive medicine specialties established for board certification in 1953, occupational medicine had a long and rich history. It developed first as “industrial medicine and surgery” in response to the Industrial Revolution and the introduction of the first government-sponsored program of social insurance (i.e., workers’ compensation) and to the need for helping workers and their families achieve better health through education and prevention. It has evolved to include toxicology and hazard recognition, driven by technology and continually emerging new hazards, maturing through epidemiology driven by the need to recognize and quantify the effect of occupational illness and disease. Over time, the specialty emphasized its relevance in environmental issues by reframing itself as “occupational and environmental medicine” (OEM). OEM physicians recognize the need to minimize or prevent health effects from a variety of both workplace and environmental hazardous exposures and coordinate practices that improve workplace and environmental health.

OEM practice has advanced significantly in the past 50 years, even though the core foundation remains clinical medicine, including musculoskeletal injury care, preplacement and surveillance evaluations, and fitness-for-duty evaluations. OEM practice expanded in the wake of the Occupational Safety and Health Act of 1970, which brought improved prevention and detection of work-related injuries and illnesses resulting from enforceable permissible exposure limits and medical surveillance requirements for designated exposures. Although some Occupational Safety and Health Act standards (e.g., lead) have not been updated to reflect current medical evidence, the National Institute for Occupational Safety and Health may provide exposure limits that reflect more current medical evidence.

The Americans With Disabilities Act of 1990 and subsequent amendments emphasized the need to put workers with disabilities on a more equal and fair footing. It has improved OEM physicians’ ability to base fitness-to-work decisions on essential job functions and bring employees back to work or keep them at work, which is increasingly important given our aging and diverse workforce. The critical nature of safe and early return to work or stay at work is a basic principle of caring for the injured worker within OEM.

OEM has always existed in dualities as both a clinical specialty for injured workers and a population-based practice for health management, with work injury care financed primarily by workers’ compensation. This sense of always facing in two directions is reflected in the history of the specialty, which at times has been a powerful engine for progressive reform and workers’ rights and at other times may have reflected paternalistic and potentially repressive policies of some employers.

PRESENT DAY

Increasing awareness that the OEM physician can affect overall worker health, workers’ families, and their environment has resulted in an expanded breadth of this medical specialty. The National Institute for Occupational Safety and Health recently established a program, Total Worker Health, which promotes a comprehensive approach to worker well-being by protecting safety and enhancing health and productivity for the benefit of workers, employers, and the nation.³ OEM physicians are increasingly asked to optimize all aspects of workers’ health. The World Health Organization also advocates for safe, healthy, and decent work for all workers and for the protection of their families from loss. The World Health Organization stresses the importance of a healthier and safer workplace to prevent disease and as a prerequisite to attain some of their Sustainable Development Goals such as ensuring healthy lives and promoting well-being, sustainable economic growth, and decent work for all.

The American College of Occupational and Environmental Medicine (ACOEM) represents OEM specialists who champion the health of workers, safety of workplaces, and quality of environment even as the workplace changes. Increased use of automation and a shift from manufacturing to service-based workers have coincided with downsizing of traditional corporate medical departments.⁴ Recently, only 15% to 26% of ACOEM members listed corporations as their primary work setting (American College of Occupational and Environmental Medicine, unpublished membership data, October 22, 2019).⁴ Most OEM physicians work in clinical settings (52%–57%), whereas others work in government jobs (9%), academic settings (7%–9%), consulting (5%–11%), and other settings.^1,4 ACOEM physician members are highly trained with 43% to 47% board certified in occupational medicine and 65% to 71% board certified in another specialty (American College of Occupational and Environmental Medicine, unpublished membership data, October 22, 2019).⁴ ACOEM publishes numerous guidance documents, position statements, and evidence-based guidelines including guidance for treatment and evaluation of law enforcement officers. ACOEM also creates evidence-based guidelines (MD Guidelines; https://acoem.org/Practice-Resources/Practice-Guidelines-Center/MDGuidelines%C2%AE) addressing treatment of a variety of work-related conditions.

Over the years, OEM training has mirrored the balance of individual and population practice, but maintaining residency programs has been a challenge, primarily because of inconsistent funding. In the United States, 25 accredited OEM residency programs currently exist; at least 18 occupational medicine programs have closed since 2000, although this trend seems to have leveled. Changes within the last three years to OEM training requirements allow programs to include a Postgraduate Year One training year to facilitate the entrance of medical school graduates and provides the option for midcareer physicians to transition to OEM with advanced standing.⁵ Residents usually have completed another residency program or have had significant clinical work experiences, a benefit to OEM. Although many practicing OEM physicians have not completed an OEM residency program, they provide a significant amount of clinical OEM care in the United States at a high level of competency. ACOEM has educational programs to help these and all practitioners improve their competency in occupational health.

In 2019, the National Academy of Medicine recommended adopting work system changes that create healthy, positive work environments for health care workers to lessen burnout.⁶ This could serve as a model for managing the workplace going forward, and OEM physicians are well suited to lead the way based on their training, experience, and expertise.

FUTURE

The continuous emergence of new chemical, infectious, and environmental hazards; advances in manufacturing and technology; pollution; climate change; substance use issues; and other events that affect the environment and workplace have increased the need for trained OEM physicians who can meet these demands. OEM practice continues to respond to new technology, to work organization changes such as the increased use of artificial intelligence and automation, to changing regulations, and to demographic trends such as the aging of the workforce. As OEM physicians respond to future challenges, the specialty will need to keep up with new developments and continue to be the champions at the forefront of worker health and the environment. OEM practice will continue to expand its scope in prevention while maintaining its role in the care of injured workers.