The Future of Occupational and Environmental Medicine

1. Robert K. McLellan, MD,MPH,FACOEM President, ACOEM The Future of Occupational and Environmental Medicine

2. Overview Trends in the workplace in occupational injury and illness in public health in the OEM workforce, training and research ACOEM Initiatives Visioning the Future of OEM

3. Changes in the American Workforce:Demographics is Our Destiny Demographics Workforce is more diverse in age, gender, race, and nationality Most new jobs in businesses with less than 500 workers Large numbers of illegal immigrant workers Nature of work Increasing proportion of service, health care, computer jobs Decreasing proportion of manufacturing, agriculture, fishing Organization of work Transient employment (temporary, contracted workers) E-commerce Homework and the 24 x 7 workweek Globalization As noted earlier, the economy added over 20 million jobs from 1988 to 1998, or an 18 percent growth. Any occupational group that expanded at a slower rate (all major occupational groups added jobs) saw its share of overall employment decline. Those occupational groups with the slowest growth and the concomitant sharpest decline in share of overall employment were agriculture, forestry, and fishing occupations and the precision production, craft, and repair occupational group, the latter of which is associated, in many instances, with manufacturing. Slower than average growth was also experienced by operators, fabricators, and laborers and also by clerical workers, groups that have seen technology lower the demand for their skills. On the other hand, very rapid growth was seen among the professional specialty and the executive, administrative, and managerial occupational groups. Marketing and sales and technician occupations also showed faster than average growth and thus saw their share of overall employment increase in the past decade. Workers in these rapidly growing occupational groups tended to be employed in very large numbers in the rapidly growing service sector (Table 4-2).TABLE 4-2 Employment by Major Occupational Group for 1988 and 1998 and Projected Employment for 2010 (in millions of persons) Occupational Group198819982010Executive, administrative, and managerial12.114.417.5Professional specialty occupations14.719.726.4Technicians and related support occupations3.94.96.1Marketing and sales occupations12.115.518.6Administrative support occupations, clerical22.124.727.0Service occupations18.422.327.8Agriculture, forestry, fishing, and related occupations3.63.83.8Precision production, craft, and repair occupations14.114.515.3Operators, fabricators, and laborers14.118.320.2Total117.8138.5162.8 As noted earlier, the economy added over 20 million jobs from 1988 to 1998, or an 18 percent growth. Any occupational group that expanded at a slower rate (all major occupational groups added jobs) saw its share of overall employment decline. Those occupational groups with the slowest growth and the concomitant sharpest decline in share of overall employment were agriculture, forestry, and fishing occupations and the precision production, craft, and repair occupational group, the latter of which is associated, in many instances, with manufacturing. Slower than average growth was also experienced by operators, fabricators, and laborers and also by clerical workers, groups that have seen technology lower the demand for their skills. On the other hand, very rapid growth was seen among the professional specialty and the executive, administrative, and managerial occupational groups. Marketing and sales and technician occupations also showed faster than average growth and thus saw their share of overall employment increase in the past decade. Workers in these rapidly growing occupational groups tended to be employed in very large numbers in the rapidly growing service sector (Table 4-2).TABLE 4-2 Employment by Major Occupational Group for 1988 and 1998 and Projected Employment for 2010 (in millions of persons) Occupational Group198819982010Executive, administrative, and managerial12.114.417.5Professional specialty occupations14.719.726.4Technicians and related support occupations3.94.96.1Marketing and sales occupations12.115.518.6Administrative support occupations, clerical22.124.727.0Service occupations18.422.327.8Agriculture, forestry, fishing, and related occupations3.63.83.8Precision production, craft, and repair occupations14.114.515.3Operators, fabricators, and laborers14.118.320.2Total117.8138.5162.8

4. Decreasing Role of Organized Labor Manufacturing union membership: 1983: 4 million 2002: under 2.5 million http://www.bizjournals.com/boston/stories/2003/04/21/focus2.html http://www.bizjournals.com/boston/stories/2003/04/21/focus2.html

5. Changes in Workplace Hazards Traditional hazards exist, but increasingly in small difficult to monitor settings or overseas Adverse effects of many contemporary occupational hazards are insidious, have long latencies, are environmentally ubiquitous and are unlikely to result in pathognomic occupational illnesses Ergonomic Stress Sedentary work life Low-level chronic exposures to environmentally pervasive agents (pthalates, nanoparticles)

6. Injuries and Illnesses in Private Industry Figure 1�21. Injuries and illnesses in private industry, 2001.Of the 5.2 million nonfatal occupational injuries and illnesses reported in 2001, 4.9 million or 93.6% were injuries. The remainder (333,800 cases or 6.4%) were work-related illnesses. Sixty-five percent (216,400 cases) of the nonfatal occupational illnesses were disorders associated with repeated trauma.(Source: BLS [2002b].)Figure 1�21. Injuries and illnesses in private industry, 2001.Of the 5.2 million nonfatal occupational injuries and illnesses reported in 2001, 4.9 million or 93.6% were injuries. The remainder (333,800 cases or 6.4%) were work-related illnesses. Sixty-five percent (216,400 cases) of the nonfatal occupational illnesses were disorders associated with repeated trauma.(Source: BLS [2002b].)

7. Illnesses in Private Industry Figure 1�22. Number of illness cases in private industry by type of illness, 1972�2001.Since 1972, BLS data illustrate significant variation in the number of reported illness cases. From 1972 to 1982, the number of illness cases declined gradually from 210,500 to 105,600. This number increased and peaked sharply in 1994 at 514,700 cases. The number of cases declined steadily to 333,800 in 2001. Disorders associated with repeated trauma declined for 7 consecutive years dating from 1995. About 216,400 cases were reported in 2001, compared with a high of 332,100 cases in 1994.(Source: BLS [2002b].)Figure 1�22. Number of illness cases in private industry by type of illness, 1972�2001.Since 1972, BLS data illustrate significant variation in the number of reported illness cases. From 1972 to 1982, the number of illness cases declined gradually from 210,500 to 105,600. This number increased and peaked sharply in 1994 at 514,700 cases. The number of cases declined steadily to 333,800 in 2001. Disorders associated with repeated trauma declined for 7 consecutive years dating from 1995. About 216,400 cases were reported in 2001, compared with a high of 332,100 cases in 1994.(Source: BLS [2002b].)

8. Number and Rate of Fatal Occupational Injuries by Age, 2002 Figure 5�1. Number and rate of fatal occupational injuries by age of worker, 2002.Workers aged 25�54 accounted for 3,672 or 66.5% of the 5,524 fatal occupational injuries in 2002. Fatality rates ranged from 1.1 per 100,000 among workers aged 16�17 to 11.5 per 100,000 among workers aged 65 and older. Fatalities among workers aged 65 and older accounted for 9% (494 fatalities) of all fatal occupational injuries. (Note: Labor force data are unavailable for youths aged 15 and younger. This precludes estimating rates for these workers.)(Source: BLS [2003a].)Figure 5�1. Number and rate of fatal occupational injuries by age of worker, 2002.Workers aged 25�54 accounted for 3,672 or 66.5% of the 5,524 fatal occupational injuries in 2002. Fatality rates ranged from 1.1 per 100,000 among workers aged 16�17 to 11.5 per 100,000 among workers aged 65 and older. Fatalities among workers aged 65 and older accounted for 9% (494 fatalities) of all fatal occupational injuries. (Note: Labor force data are unavailable for youths aged 15 and younger. This precludes estimating rates for these workers.)(Source: BLS [2003a].)

9. Median Days Lost due to Occupational Injury or Illness by Age Figure 5�3. Median days away from work due to occupational injury or illness in private industry by age, 2001.Median days away from work due to injury or illness increased with age. In 2001, workers aged 14�15 and 16�19 had median work losses of 2 and 4 days, respectively. Workers aged 55�64 and 65 and older had median work losses of 10 and 14 days, respectively.(Sources: BLS [2003b,c].)Figure 5�3. Median days away from work due to occupational injury or illness in private industry by age, 2001.Median days away from work due to injury or illness increased with age. In 2001, workers aged 14�15 and 16�19 had median work losses of 2 and 4 days, respectively. Workers aged 55�64 and 65 and older had median work losses of 10 and 14 days, respectively.(Sources: BLS [2003b,c].)

10. Occupational Health and Safety:37 years after the OSHAct 37 yrs after OSHA Act Injury/Illness incidence has fallen from 11.0 to 4.6 per 100 full time workers But A worker becomes ill or is injured on the job every 2.5 secs A worker dies every 8 minutes

11. Persistent Undercounting Occupational Injury and Disease? No comprehensive national surveillance system Under the table employment or regulatory exclusion Bureau of Labor Statistics annual survey, Workers Comp, and physician reporting data bases not integrated Legal and scientific challenges in establishing causation Number of new injuries and illnesses underestimated by several hundred percent http://www.ajph.org/cgi/reprint/92/9/1421 World Trade Center coughhttp://www.ajph.org/cgi/reprint/92/9/1421 World Trade Center cough

12. Regulatory Politics OSHA Many exposure standards date to 1971 Difficult to update 1992 court decision stymied effort of global standard update to synch with the annually revised ACGIH TLVs Little enforcement clout 2000 inspectors (risk of inspection once in 88 years) Fish and Game has 6 times the number of inspectors 2005 Avg penalty for a serious violation: $9000 A cost of doing business?

13. Relaxation of Worker Protection Rules During Disasters OSHA Respiratory Protection standard never enforced No > 60% of rescue workers ever wore respirators, usually about 20%OSHA Respiratory Protection standard never enforced No > 60% of rescue workers ever wore respirators, usually about 20%

14. Workers Compensation Reform:Driven by Rising Costs State by state Disability management Requirement for TAD Case management Worksite initiatives MD education Optimizing medical care Utilization review Treatment guidelines

15. General Health Trends � A Public Health Crisis Population is aging Obesity and sedentary lifestyle and associated diseases are epidemic and will drive disability Health care premiums rising at twice the inflation rate Number of uninsured Americans continues to rise 46.6 million or 15.9% of population Health insurance coverage for working families � has declined annually for 6 years. Now at 62% http://www.epinet.org/content.cfm/bp175 http://www.kff.org/insurance/7031/print-sec3.cfmhttp://www.epinet.org/content.cfm/bp175 http://www.kff.org/insurance/7031/print-sec3.cfm

16. Wide Variation In Treatment and Costs

17. Evidence Based Medicine and Treatment Guidelines Small area analysis Critical appraisal Evidence review and consensus Cochrane Collaboration Clinical epidemiology Outcomes research Randomized clinical trials Agency for Healthcare Quality and Research (formerly AHCPR) Care maps, algorithms, guidances, pay for performance

18. Trends in the OEM Workforce

19. OEM Workforce Total Occupational Health and Safety Professionals 75,000 � 125,000 AMA estimates 10,000 physicians practice some OM 3,332 Board-certified occupational medicine physicians since 1955 Only 1,500 - 1,800 are actually in practice today About 100 new diplomates per year ACOEM 5100 members Mean age 55 93% > 40 Safe Work in the 21st Century: Education and Training Needs for the Next Decade's Occupational Safety and Health Personnel (2000)Institute of Medicine (IOM) http://books.nap.edu/openbook.php?record_id=9835&page=33Safe Work in the 21st Century: Education and Training Needs for the Next Decade's Occupational Safety and Health Personnel (2000)Institute of Medicine (IOM) http://books.nap.edu/openbook.php?record_id=9835&page=33

20. ACOEM Members Practice Sites 1992 v 2006

21. OEM Training Declining number of residency programs 1994: 42 2007: 31 Declining number of graduates 1994 : 168 2007: 101 Educational Resource Centers Flat, unstable funding

23. ACOEM�s Strategic Response Excellence in health care Health and productivity Workforce protection through emergency preparedness

24. Excellence in Healthcare ACOEM OM Practice Guidelines, 2nd ed Providing the best care, at the right time, every time� Better outcomes at less cost Updated Methodology, roll out of updated chapters The Value of OEM � ACOEM (OEM) gains credibility, prominence, and influence Valuing excellence in occupational health care with upgraded fee schedules Note: value�Kurt Hegeman Kathryn Mueller Michael Weiss The ACOEM Utilization Management Knowledgebase (UMK) is a breakthrough tool for managing treatment plans and patient care. The UMK assists in evaluating, tracking and reporting the medical necessity and/or appropriateness of health care services. It is fully referenced and medically consistent with ACOEM�s Occupational Medicine Practice Guidelines, 2nd Edition, and APG Insights Note: value�Kurt Hegeman Kathryn Mueller Michael Weiss The ACOEM Utilization Management Knowledgebase (UMK) is a breakthrough tool for managing treatment plans and patient care. The UMK assists in evaluating, tracking and reporting the medical necessity and/or appropriateness of health care services. It is fully referenced and medically consistent with ACOEM�s Occupational Medicine Practice Guidelines, 2nd Edition, and APG Insights

25. Excellence in Health Care Promote the Future of OEM Enhance training opportunities � White Paper Funding Training Models CME in core competencies of OEM Preventive Medicine and Public Health Training Act of 2007 IOM 2007: Training Physicians for Public Health Careers

26. Redefining Core OEM Competencies Clinical Occupational and Environmental Medicine OEM Related Law and Regulations Environmental Health Work Fitness and Disability Integration Toxicology Hazard Recognition, Evaluation, and Control Disaster Preparedness and Emergency Management Health and Productivity Public Health, Surveillance, and Disease Prevention OEM Related Management and Administration Training Physicians for Public Health Careers � does not explicity address occ med training needs. Says 10000 added PH trained md needed http://www.iom.edu/CMS/3793/33137/43413.aspx Training Physicians for Public Health Careers � does not explicity address occ med training needs. Says 10000 added PH trained md needed http://www.iom.edu/CMS/3793/33137/43413.aspx

27. Excellence in Health CareEnvironmental Medicine Hippocrates On Airs, Waters, and Places (c 400 BC) Enormous public concern and daily dose of issues 1998 Keynote National Leadership Forum for Health Care Professionals �How to persuade physicians to consider environmental issues in assessing and treating their patients?� ACOEM changed its name to include Environmental Medicine ACOEM changed its name to include Environmental Medicine

28. Environmental Medicine 1992: ACOM becomes ACOEM A core competency Environmental Medicine Core Curriculum Increasing presence in courses, OEM journals 2007 What are the career opportunities? What about in practice? AOHC 2008

29. Social Justice Maldistribution of risk and burden of poor health Protection of vulnerable groups Updating ACOEM code of ethics Section for Underserved Populations

30. #2 Health and Productivity:ACOEM as Thought Leader

31. Promoting Employee Health: Cost or Investment? Impact of health on human and business performance shifting from cost to be justified to an investment to be leveraged Will HPM decrease the burden on SSDI and Medicare

32. Health and Productivity Initiatives NIOSH WorkLife Workshop Health and Productivity Center HPM tools Revised tool Kit HPM Webinar Curriculum HPM clinic Cornerstone collaboration with payers, employers and labor to prevent and manage disability Implications of HPM for Social Security Disability and Medicare

33. #3 Workforce Protection:Mandate of Homeland Security

34. Disasters Threaten Workers and the Workforce as a Critical Infrastructure for Business Continuity protection of workers health and workforceprotection of workers health and workforce

35. A New Message for Employers

36. Equipping OH Professionals With The Right Tools Education SOTAC 2006 was a surprising disaster! (drill) Just in time webinars OHDEN � Occupational Disaster Expert Network � a web-based tool kit for OH professionals Currently Under construction at www.acoem.org See the full featured prototype

37. Implications of the Trends In US Workforce and global economic changes complicate implementation of workplace health and safety programs and the monitoring of occupational injuries and illnesses Looming public health crisis/opportunity Fate of OEM parallels societal protection of workers (and the environment?) Safe Work in the 21st Century: Education and Training Needs for the Next Decade's Occupational Safety and Health Personnel (2000) Institute of Medicine Need more OSH professionals at all levels. The authoring committee also concludes that OSH education and training needs to place a much greater emphasis on injury prevention and that current OSH professionals need easier access to more comprehensive and alternative learning experiences. In addition, provision of adequate training for the majority of American workers will depend upon the discovery of new and improved ways of reaching small and mid-sized industries with increasingly decentralized and highly mobile workforces. Ten recommendations address current and future OSH workforces and training programs. ments, among others, have become commonplace, challenging the traditional model for the provision of OSH programs. Important changes are also occurring in the health care system, most notably the increased emphasis on managed care and other means of reducing costs. As yet unexplored are the implications of this new care delivery system for occupational physicians, as well as possible changes in the roles of primary care physicians, nurse practitioners, and physician assistants who may be treating workers. From a regulatory standpoint, OSHA has added job safety standards over the years that include requirements that �qualified,� �designated,� or �competent� persons ensure their enforcement at the work site, but there has been no agreement as to what type of training might enable such personnel to meet these requirements. OSHA also mandates training of workers in more than 100 of its standards, but it does not speak to the quantity, quality, or efficacy of that training. Few if any standards call for the training of employers or of managers responsible for workplace safety and health. http://books.nap.edu/openbook.php?record_id=9835&page=239 Safe Work in the 21st Century: Education and Training Needs for the Next Decade's Occupational Safety and Health Personnel (2000) Institute of Medicine Need more OSH professionals at all levels. The authoring committee also concludes that OSH education and training needs to place a much greater emphasis on injury prevention and that current OSH professionals need easier access to more comprehensive and alternative learning experiences. In addition, provision of adequate training for the majority of American workers will depend upon the discovery of new and improved ways of reaching small and mid-sized industries with increasingly decentralized and highly mobile workforces. Ten recommendations address current and future OSH workforces and training programs. ments, among others, have become commonplace, challenging the traditional model for the provision of OSH programs. Important changes are also occurring in the health care system, most notably the increased emphasis on managed care and other means of reducing costs. As yet unexplored are the implications of this new care delivery system for occupational physicians, as well as possible changes in the roles of primary care physicians, nurse practitioners, and physician assistants who may be treating workers. From a regulatory standpoint, OSHA has added job safety standards over the years that include requirements that �qualified,� �designated,� or �competent� persons ensure their enforcement at the work site, but there has been no agreement as to what type of training might enable such personnel to meet these requirements. OSHA also mandates training of workers in more than 100 of its standards, but it does not speak to the quantity, quality, or efficacy of that training. Few if any standards call for the training of employers or of managers responsible for workplace safety and health. http://books.nap.edu/openbook.php?record_id=9835&page=239

38. We Need Improved systems of occupational injury and illness reporting New research needed to explore risk and control of new hazards New training, funding systems and regulatory reform New health care financing/delivery systems New approaches to meeting the OH needs of the underserved populations at home and abroad

39. Making Progress in Protecting Workers? Align worker protection with themes of health and human rights Create a zero injury and illness culture Achieve 100% �coverage� of all workers by competent OEM and OHS programs Form coalitions around issues of importance to business, labor, environmental groups, community groups, public health professionals

40. Where the Future? OM physicians are public health professionals for the employed population OH constitutes a parallel healthcare system, with different capabilities and drivers OH services support productivity but also protect the future of the enterprise and the critical human resource needed for all economic sectors May protect social welfare systems from bankruptcy

41. OH can play a key role in public health Disaster management Population health promotion Environmental medicine A new Business case for OEM! National security case for OEM! Public health case for OEM! Where the Future?

42. ACOEM�s Vision and Mission We champion the health and safety of workers, workplaces, and environments We are the specialty that is �devoted to prevention and management of occupational and environmental injury, illness and disability, and promotion of health and productivity of workers, their families, and communities.�