Industrial medical programmes vary in both content and structure. It is a common conception that industrial medical programmes are supported only by large corporations and are comprehensive enough to evaluate all workers for all possible adverse effects. However, the programmes implemented by industries vary considerably in their scope. Some programmes offer only pre-placement screening, while others offer total medical surveillance, health promotion and other special services. In addition, the structures of programmes differ from one another, as do the members of the safety and health teams. Some programmes contract with an off-site physician to perform medical services, while others have a health unit at the site staffed by physicians and nursing personnel and backed by a staff of industrial hygienists, engineers, toxicologists and epidemiologists. The duties and responsibility of these members of the safety and health team will vary according to the industry and the risk involved.
Motivation for Industrial Medical Programmes
The medical monitoring of workers is motivated by multiple factors. First, there is the concern for the general safety and health of the employee. Second, a monetary benefit results from a surveillance effort through increased productivity of the employee and reduced medical care costs. Third, compliance with the Occupational Safety and Health Act (OSHA), with equal employment opportunity requirements (EEO), the Americans with Disabilities Act (ADA) and other statutory guidelines is mandatory. Finally, there is the spectre of civil and criminal litigation if adequate programmes are not established or are found to be inadequate (McCunney 1995; Bunn 1985).
Types of Occupational Health Servicesand Programmes
Occupational health services are determined through a needs assessment. Factors that affect which type of occupational health service is to be utilized include the potential risks of normal operations, the demographics of the workforce and management’s interest in occupational health. Health services are dependent on the type of industry, the physical, chemical or biological hazards present, and the methods used to prevent exposure, as well as government and industry standards, regulations and rulings.
Important general health services tasks include the following:
- evaluation of employees’ ability to perform their assigned duties in a safe manner (via pre-placement evaluations)
- recognition of early symptoms and signs of work-related health effects and appropriate intervention (medical surveillance examinations can reveal these)
- provision of treatment and rehabilitation for occupational injuries and illnesses and non-occupational disorders that affect work performance (work-related injuries)
- promotion and maintenance of employees’ health (wellness)
- evaluation of a person’s ability to work in light of a chronic medical disorder (an independent medical examination is required in such a case)
- supervision of policies and programmes related to worksite health and safety.
Location of Health Services Facilities
Delivery of occupational health services today is increasingly provided through contractors and local medical facilities. However, onsite services formed by employers were the traditional approach taken by industry. In settings with a substantial number of employees or certain health risks, onsite services are cost-effective and provide high-quality services. The extent of these programmes varies considerably, ranging from part-time nursing support to a fully-staffed medical facility with full-time physicians.
The need for onsite medical service is usually determined by the nature of the company’s business and the potential health hazards present in the workplace. For example, a company that uses benzene as a raw material or ingredient in its manufacturing process will probably need a medical surveillance programme. In addition, many other chemicals handled or produced by the same plant may be toxic. In these circumstances, it may be economically feasible as well as medically advisable to provide onsite medical services. Some onsite services provide occupa-tional nursing support during daytime working hours and may also cover second and third shifts or weekends.
Onsite services should be performed in plant areas compatible with the practice of medicine. The medical facility should be centrally located to be accessible to all employees. Heating and cooling needs should be considered to permit the most economical use of the facility. A rule of thumb that has been used in allocating floor space to an in-house medical unit is one square foot per employee for units servicing up to 1,000 employees; this figure should probably include a minimum of 300 square feet. The cost of space and several relevant design considerations have been described by specialists (McCunney 1995; Felton 1976).
For some manufacturing facilities located in rural or otherwise remote areas, services may usefully be provided in a mobile van. If such an installation is made available, the following recommendations may be made:
- Assistance should be furnished to companies whose in-house medical services are not fully equipped to cope with medical surveillance programmes that require the use of special equipment, such as audiometers, spirometers or x-ray machines.
- Medical surveillance programmes should be made available in remote geographical areas, especially to ensure uniformity in data collected for epidemiology studies. For example, to enhance the scientific accuracy of a study of occupational lung disorders, a similar spirometer should be used and the preparation of chest films should be performed according to appropriate international standards, such as those of the International Labour Organization (ILO).
- Data from different sites should be coordinated for entry into a computer software programme.
A company that relies on a mobile van service, however, will still require a physician to conduct pre-placement examinations and to assure the quality of the services provided by the mobile van company.
Services Most Commonly Performedin the In-house Facility
An onsite assessment is essential to determine the type of health services appropriate for a facility. The most common services provided in the occupational health setting are pre-placement evaluations, assessment of work-related injury or illness and medical surveillance examinations.
The pre-placement examination is performed after a person has been given a conditional offer of a job. The ADA uses pre-employment to mean that the person is to be hired if he or she passes the physical examination.
The pre-placement examination should be performed with attention to the job duties, including physical and cognitive requirements (for safety sensitivity) and potential exposure to hazardous materials. The content of the examination depends on the job and the worksite assessment. For example, jobs that require use of personal protective equipment, such as a respirator, often include a pulmonary function study (breathing test) as part of the pre-placement examination. Those involved in the US Department of Transportation (DOT) activities usually require urinary drug testing. To avoid errors in either the content or the context of the examination, it is advisable to develop standard protocols to which the company and the examining physician agree.
After the examination, the physician provides a written opinion about the person’s suitability for performing the job without health or safety risk to self or others. Under usual circumstances, medical information is not to be divulged on this form, merely fitness for duty. This form of communication can be a standard form that should then be placed in the employee’s file. Specific medical records, however, remain at the health facility and are maintained only by a physician or nurse.
Work-related injuries and illnesses
Prompt, quality medical care is essential for the employee sustaining a work-related injury or occupational illness. The medical unit or contract physician should treat employees who are injured at work or who experience work-related symptoms. The company’s medical service has an important role to play in the management of workers’ compensation costs, especially in performing return-to-work assessments following absence due to an illness or injury. A major function of the medical professional is the coordination of rehabilitation services of such absentees to insure a smooth return to work. The most effective rehabilitation programmes make use of modified-duty or alternative assignments.
An important task of the company’s medical adviser is to determine the relationship between exposure to hazardous agents and illness, injury or impairment. In some states, the employee may choose his or her attending physician, whereas in other states the employer may direct or at least suggest evaluation by a specific physician or health care facility. The employer usually has the right to specify a physician to conduct a “second opinion” examination, especially in the context of a protracted recovery or serious medical disorder.
The nurse or physician advises management on the recordability of occupational injuries and illnesses in accordance with OSHA record-keeping requirements, and needs to be familiar with both OSHA and Bureau of Labor Statistics (BLS) guidelines. Management must assure that the health care provider is thoroughly familiar with these guidelines.
Medical surveillance examinations
Medical surveillance examinations are required by some OSHA standards for exposure to some substances (asbestos, lead and so on) and are recommended as being in accordance with good medical practice for exposure to others, such as solvents, metals and dusts such as silica. Employers must make these examinations, when required by OSHA standards, available at no cost to employees. Although the employee may decline to participate in an examination, the employer may specify that the examination is a condition of employment.
The purpose of medical surveillance is to prevent work-related illnesses through early recognition of problems, such as abnormal laboratory results that may be associated with the early stages of a disease. The employee is then re-evaluated at subsequent intervals. Consistency in the medical follow-up of abnormalities uncovered during medical surveillance examinations is essential. Although management should be apprised of any medical disorders related to work, medical conditions not arising from the workplace should remain confidential and be treated by the family physician. In all cases, employees should be informed of their results (McCunney 1995; Bunn 1985, 1995; Felton 1976).
Although the occupational health physician and nurse are most readily recognized through their hands-on medical skills, they can also offer significant medical advice to any business. The health professional can develop procedures and practices for medical programmes including health promotion, substance abuse detection and training, and medical record-keeping.
For facilities with an in-house medical programme, a policy for the management of medical waste handling and related activities is necessary in accordance with the OSHA blood-borne pathogen standard. Training with respect to certain OSHA standards, such as the Hazard Communication Standard, the OSHA Standard on Access to Exposure and Medical Records, and OSHA record-keeping requirements, is an essential ingredient to a well-managed programme.
Emergency response procedures should be developed for any facility that is at increased risk of natural disaster or that handles, uses or manufactures potentially hazardous materials, in accordance with the Superfund Act Reauthorization Amendment (SARA). Principles of medical emergency response and disaster management should, with the assistance of the company’s physician, be incorporated in any site emergency response plan. Since the emergency procedures will differ depending on the hazard, the physician and nurse should be prepared to handle both physical hazards, such as those that occur in a radiation accident, and chemical hazards.
Health promotion and wellness programmes to educate people on the adverse health effects of certain lifestyles (such as cigarette smoking, poor diet and lack of exercise) are becoming more common in industry. Although not essential to an occupational health programme, these services can be valuable to employees.
The incorporation of wellness and health promotion plans in the medical programme is recommended whenever feasible. The objectives of such a programme are a health-conscious, productive workforce. Health care costs can be reduced as a result of health promotion initiatives.
Substance Abuse Detection Programmes
Within the past few years, especially since the US Department of Transportation (DOT) Ruling on Drug Testing (1988), many organizations have developed drug testing programmes. In the chemical and other manufacturing industries, the most common type of urinary drug test is performed at the pre-placement evaluation. The DOT rulings on drug testing for interstate trucking, gas transmission operations (pipelines), and the railroad, coast guard and aviation industries are considerably broader and include periodic testing “for cause,” that is, for reasons of suspected substance abuse. Physicians are involved in drug screening programmes by reviewing results to assure that reasons other than illicit drug use are eliminated for individuals with positive tests. They must ensure the integrity of the testing process and confirm any positive test with the employee before releasing the results to management. An employee assistance programme and uniform company policy are essential.
Medical records are confidential documents which should be maintained by an occupational physician or nurse and stored in such a manner so as to protect their confidentiality. Some records, such as a letter indicating a person’s fitness for respirator use, should be kept onsite in the event of a regulatory audit. Specific medical test results, however, should be excluded from such files. Access to such records should be limited to the health professional, the employee and other persons designated by the employee. In some instances, such as the filing of a workers’ compensation claim, confidentiality is waived. The OSHA Access to Employee Exposure and Medical Records standard (29 CFR 1910.120) requires that employees be informed annually of their right of access to their medical records and of the location of such records.
Confidentiality of medical records must be preserved in accordance with legal, ethical and regulatory guidelines. Employees should be informed when medical information will be released to management. Ideally, an employee will be asked to sign a medical form that authorizes release of certain medical information, including laboratory tests or diagnostic material.
The first item in the American College of Occupational and Environmental Medicine Code of Ethics requires that “Physicians should accord the highest priority to the health and safety of individuals in both the workplace and the environment.” In the practice of occupational medicine, both employer and employee benefit if physicians are impartial and objective and apply sound medical, scientific and humanitarian principles.
In international occupational and environmental medicine, physicians working for US industries will have not only the traditional responsibilities of occupational and environmental physicians but will also have significant clinical management responsibilities. The responsibility of the medical department will include the clinical care of the employees and commonly the spouses and children of the employees. Servants, extended family and the community are often included in the clinical responsibilities. In addition, the occupational physician will also have responsibilities for occupational programmes related to workplace exposures and risks. Medical surveillance programmes, as well as pre-employment and periodic examinations are critical programme components.
Designing appropriate health promotion and prevention programmes is also a major responsibility. In the international arena, these prevention programmes will include issues in addition to those lifestyle issues commonly considered in the United States or Western Europe. Infectious diseases require a systematic approach to needed vaccination and chemoprophylaxis. Educational programmes for prevention must include attention to food-, water- and blood-borne pathogens and to general sanitation. Accident prevention program-mes must be considered in view of the high risk for traffic-related deaths in many developing countries. Special issues such as evacuation and emergency care must be given detailed scrutiny and appropriate programmes implemented. Environmental exposure to chemical, biological and physical hazards is often increased in developing countries. Environmental prevention programmes are based on multi-staged education plans with indicated biological testing. The clinical programmes to be developed internationally may include inpatient, outpatient, emergency and intensive care management of expatriates and national employees.
An ancillary programme for international occupational physicians is travel medicine. The safety of short-term rotational travellers or foreign residents requires special knowledge of the indicated vaccinations and other preventive measures on a global basis. In addition to recommended vaccinations, a knowledge of medical requirements for visas is imperative. Many countries require serologic testing or chest x rays, and some countries may take into account any significant medical condition in the decision to issue a visa for employment or as a residency requirement.
Employee assistance and marine and aviation programmes are also commonly included within the international occupational physician’s responsibilities. Emergency planning and the provision of appropriate medications and training in their use are challenging issues for sea and air vessels. Psychological support both of expatriate and national employees is often desirable and/or necessary. Employee assistance programmes may be extended to expatriates and special support given to family members. Drug and alcohol programmes should be considered within the social context of the given country (Bunn 1995).
In conclusion, the scope and organization of corporate occupational health programmes may vary widely. However, if appropriately discussed and implemented, these programmes are cost-effective, protect the company from legal liabilities and promote the occupational and general health of the workforce.