The Future of Occupational and Environmental Medicine

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

2. 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 Overview

3. 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 Changes in the American Workforce:Demographics is Our Destiny

4. Decreasing Role of Organized Labor • Manufacturing union membership: • 1983: 4 million • 2002: under 2.5 million Bureau of Labor Statistics

5. 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) Changes in Workplace Hazards

6. Injuries and Illnesses in Private Industry NIOSH Worker Health Chartbook 2004

7. Illnesses in Private Industry NIOSH Worker Health Chartbook 2004

8. Number and Rate of Fatal Occupational Injuries by Age, 2002 NIOSH Worker Health Chartbook 2004

9. Median Days Lost due to Occupational Injury or Illness by Age NIOSH Worker Health Chartbook 2004

10. 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 Occupational Health and Safety:37 years after the OSHAct

11. 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 Persistent Undercounting Occupational Injury and Disease? Azaroff Am J Pub Hlth 2002

12. 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? Regulatory Politics

13. Relaxation of Worker Protection Rules During Disasters

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

15. 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% General Health Trends – A Public Health Crisis

16. Wide Variation In Treatment and Costs Ratio of Total Rates of Spine Surgery to the U.S. Average by Hospital Referral Region (2002-03) Source: Spine Surgery. A Report by the Dartmouth Atlas of Healthcare. CMS-FDA Collaborative.

17. 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 Evidence Based Medicine and Treatment Guidelines

18. Trends in the OEM Workforce

19. 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 OEM Workforce

20. ACOEM Members Practice Sites 1992 v 2006

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

22. * Success rates are for the combined R01, R03, and R21 mechanisms only

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

24. 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 Excellence in Healthcare

25. 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 Excellence in Health Care

26. 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 Redefining Core OEM Competencies

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?”

28. 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 Environmental Medicine

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

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. 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 Health and Productivity Initiatives

33. #3 Workforce Protection:Mandate of Homeland Security

34. Disasters Threaten Workers and the Workforce as a Critical Infrastructure for Business Continuity Industrial Accidents Terrorism Natural Disasters

35. A New Message for Employers Traditional New Message $ World of Hurt “Occupational health services can make your company more profitable.” “Occupational health services could save your butt in a real emergency.”

36. 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 Equipping OH Professionals With The Right Tools

37. 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?) Implications of the Trends In US

38. 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 We Need

39. 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 Making Progress in Protecting Workers? Silverstein 2007 & Rantenan 2007

40. 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 Where the Future?

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. 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.” ACOEM’s Vision and Mission