ACOEM-OEM-COMPETENCIES.Pdf

ACOEM GUIDANCE STATEMENT

American College of Occupational and Environmental Medicine’s Occupational and Environmental Medicine Competencies—2014

ACOEM OEM Competencies Task Force∗

*Marianne Cloeren, MD, MPH, Constantine Gean, MD, MBA, MS, Denece Kesler, MD, MPH, Judith Green-McKenzie, MD, MPH, Mark Taylor, MD, MPH, Mark Upfal, MD, MPH, Michael Hodgson, MD, MPH, Philip Adamo, MD, MPH, Philip Harber, MD, MPH, and Robert McLellan, MD, MPH

n 1998, the American College of Oc- The preventive medicine foundation of oc- Board certification in occupational I cupational and Environmental Medicine cupational medicine impacts all the different medicine provides training related to each (ACOEM) recognized the need for defin- practice areas of OEM, whether it involves of the core competencies described in this ing important competencies for occupa- preventing illness related to a hazardous document and establishes the foundation for tional and environmental medicine (OEM) exposure, treating injury due to an employee OEM specialists to rapidly expand their com- physicians and published its original set of health condition, or addressing unnecessary petence in focused areas during the trajec- OEM Competencies,1 which were updated work disability after an occupational injury. tory of their career. The public may confirm in 2008.2 The evolving US health care sys- The OEM physicians are required to whether an OEM physician is board certi- tem, along with recently published research effectively interact with a wide range of other fied via the American Board of Preventive on how OEM physicians actually practice professionals and provide guidance not only Medicine (http://www.theabpm.org), which medicine,3–8 the increasing globalization of to patients but also to other clinicians and oc- maintains a list of board-certified allopathic the workplace, and changes in the way US cupational health nurses, employers, safety (MD) occupational medicine physicians, or medical residency programs define clinical and industrial hygiene professionals, human the American Osteopathic Board of Preven- competency,9–15 all contributed to the need resource managers, attorneys, labor unions, tive Medicine (http://www.aobpm.org/index for a fresh look at OEM Competencies,pre- and public health care professionals. In these .cfm), which certifies doctors of osteopathy sented in this revised document. interactions, OEM physicians should follow a (DO) medicine. Occupational and environmental strict code of ethics related to matters of con- Recent research3–5,15 on OEM careers medicine focuses on the interactions be- fidentiality and potential conflicts of interest. and environments has shown that OEM tween work and health, and physicians Detailed guidance in this area is provided in physicians practice in three broad clinical who practice OEM need to understand how ACOEM Code of Ethics.16 Effective commu- areas, which can be loosely categorized to prevent, evaluate, and manage adverse nication in OEM includes risk communica- as follows: (1) clinical care (eg, workers’ health effects from work and environmental tion, patient education, workforce education, compensation injury care and work-related hazards. This is the traditional view of development of policy and guidance docu- examinations), (2) clinical subspecialty care OEM as “industrial medicine.” Increasingly, ments, and medical/legal document prepara- (eg, toxicology evaluations, medical/legal however, OEM physicians have become the tion. work, and case management), and (3) man- leading experts on mitigating the impact Physicians practicing OEM typically agement/population health (eg, corporate of health conditions on work. In practice, have a much more diverse background than employee health program management and this includes managing employee absences, those practicing in most other areas of OEM research). It is important for physi- evaluating work capacity, preventing work medicine. The paths toward board certifi- cians who are board certified in occupational disability, assessing fitness for work, advis- cation in occupational medicine are via the medicine to be prepared to work in all of ing on appropriate work restrictions, and American Board of Preventive Medicine or these practice environments—many OEM implementing employee wellness programs. the American Osteopathic Board of Preven- physicians’ practices include all three focus tive Medicine. Nevertheless, most physicians areas. Nevertheless, not all physicians prac- engaged in the practice of OEM (and most ticing OEM need equivalent competency in From the American College of Occupational and En- ACOEM members) are not board certified these diverse areas. vironmental Medicine, Elk Grove Village, Ill. The American College of Occupational and Environ- in occupational medicine but are certified in This document organizes the topic mental Medicine emphasizes that the judgments other medical fields. Thus, the OEM Compe- areas relevant to OEM practice and describes expressed herein represent the best available evi- tencies use the term OEM physician gener- the expected basic competency within that dence at the time of publication and shall be con- ically without specification of board cer- area for all OEM physicians. This is then sidered the position of ACOEM and not the individual opinions of contributing authors. tification. Physicians without occupational followed by the knowledge areas and skill The American College of Occupational and Environ- medicine board certification can take ad- sets for each of the 10 core competencies mental Medicine requires all substantive contrib- vantage of several training courses available for OEM physicians, with examples of how utors to its documents to disclose any potential through ACOEM and other organizations this clinical competency is reflected on the competing interests, which are carefully considered. The authors declare no conflicts of interest. that are designed to help such physicians basis of whether they practice in patient Address correspondence to: American College of Oc- learn the basics of OEM, or develop highly care settings as clinical OEM subspecialty cupational and Environmental Medicine, 25 NW specific content knowledge required to effec- experts or in program or population health Point Blvd, Ste 700, Elk Grove Village, IL 60007 tively deliver OEM-related clinical services, management. Physicians who are board ([email protected]). Copyright C 2014 by American College of Occupa- such as medical review officer (MRO), com- certified in occupational medicine are tional and Environmental Medicine mercial driver medical examination, or per- expected to already have (or be prepared to DOI: 10.1097/JOM.0000000000000173 formance of impairment rating examinations. rapidly develop) the skills and knowledge

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sets needed to deliver care in any of the three based clinical evaluation and treatment of worker can safely be at work and complete clinical subsets of care. injuries and illnesses that are occupationally required job tasks. The physician should be This document also indicates which of or environmentally related. The OEM able to assist the patient in identifying per- the Accreditation Council for Graduate Med- physician’s expertise is also applied to sonal functional goals, and develop a treat- ical Education (ACGME) six core competen- evaluating the impact of personal medical ment or management plan that attempts to cies are primarily addressed by the specific conditions on the ability to perform work align the patient’s goals with the job require- OEM competency area. These six core com- tasks. Throughout the course of care, the ments. The physician should have the knowl- petency areas are (1) ACGME Patient Care, physician should seek to maximize the pa- edge and skills necessary to provide guid- (2) Medical Knowledge, (3) Practice-Based tient’s functional recovery. Clinical expertise ance to the employee and employer when Learning and Improvement, (4) Interper- is applied in face-to-face care of patients, as there is a need for integration of an em- sonal and Communication Skills, (5) Profes- well as in activities such as case management ployee with a disability into the workplace, sionalism, and (6) Systems-Based Practice. and peer-to-peer discussions. (ACGME core or when there is a need to pursue other av- Appendix 1 contains the text for the ACGME competencies addressed: ACGME Patient enues such as vocational rehabilitation or competencies related to OEM practice. Ap- Care, Medical Knowledge, Interpersonal and disability benefits. (ACGME core compe- pendix 2 contains a link to the 30-page Pre- Communication Skills, and Professionalism.) tencies addressed: ACGME Patient Care, ventive Medicine Milestone Project: Occupa- Medical Knowledge, Interpersonal and Com- tional Medicine for training in occupational OEM-Related Law munication Skills, Professionalism, and medicine board certification. These should and Regulations Systems-Based Practice.) be considered reference documents, relevant The OEM physician should have the to the current training of new OEM physi- knowledge and skills necessary to comply cians seeking board certification. Appendix 3 with regulations important to occupational Toxicology is related to competency in techniques and and environmental health, as well as the wide The OEM physician should have the methodologies of research and education. range of laws and regulations related to the knowledge and skills to recognize, evalu- For the purpose of this document, interactions between work and health. As ate, and treat health effects of exposures to competency is defined as possession of suf- recognized experts on issues relating to the toxic agents at work or in the general en- ficient physical, intellectual, and behavioral causation of occupational and environmen- vironment. The physician should also have qualifications (ie, knowledge, skills, abilities, tal injuries and illnesses, as well as ability the knowledge and skill to develop, evaluate, and attitudes) to perform a task or serve in a to perform work with or without reasonable and manage medical surveillance and bio- role that adequately accomplishes a desired accommodations, OEM physicians are fre- logical monitoring programs for toxicologi- outcome. In order for OEM physicians to quently called on to provide expert testimony, cal exposures. (ACGME core competencies have a solid identity with employers, gov- write expert opinion reports, and provide addressed: ACGME Patient Care, Medical ernment agencies, health care organizations, peer review. The OEM physician needs to Knowledge, Practice-Based Learning and and other health care practitioners, a short list interact knowledgeably with nonmedical pro- Improvement, Professionalism, and Systems- of core competencies is essential. This docu- fessionals, including human resources man- Based Practice.) ment presents a list of 10 core competencies agers, operations managers, safety profes- that identify the areas of medicine that are sionals, union leaders, government officials, the basis of the OEM specialty. and legal professionals, and should under- Hazard Recognition, Evaluation, A systematic process was used to ar- stand the rules of these worlds. (ACGME and Control rive at the competencies. The task force that core competencies addressed: ACGME The OEM physician should have the developed this document represents diverse Practice-Based Learning and Improve- knowledge and skills necessary to assess practices, including academic, corporate, pri- ment, Interpersonal and Communication whether there is risk of an adverse event vate practice, and government. The prior Skills, Professionalism, and Systems-Based from exposure to physical, chemical, bio- competencies document was reviewed. Then, Practice.) logical, ergonomic, or psychological haz- the OEM competencies in use by other orga- ards in the workplace or environment. The nizations and countries were evaluated,17 as Environmental Health OEM physician should be prepared to col- were other current publications as outlined in The OEM physician should have the laborate with industrial hygienists or other the references. Input was sought by experts in knowledge and skills necessary to recognize qualified safety and health care profession- specific content area. Finally, review and in- potential environmental causes of concern als and interpret measurements and reports put were solicited from the ACOEM Special to the individual, as well as to community from such professionals in context. If there Interest Sections. health. Environmental issues most often is a risk with exposure, then that risk can include air, water, or ground contamination be characterized with recommendations for OEM CORE COMPETENCIES by natural or artificial pollutants. The control measures or medical surveillance. A physician specializing in OEM is physician should know about the health The OEM physician should demonstrate an expected to be competent in all 10 core com- effects of the broad physical and social understanding of the core principles of in- petencies, with knowledge and skills that are environment, which includes housing, urban dustrial hygiene, ergonomics, occupational specific to the area of clinical practice fo- development, land use and transportation, safety and risk/hazard control, and communi- cus. The OEM physician should endeavor industry, and agriculture. (ACGME core cation, and apply the principles of the Hierar- to apply evidence-based best practices (eg, competencies addressed: ACGME Patient chy of Controls to protect the health of indi- shared medical decision-making), outcome Care, Medical Knowledge, Interpersonal vidual workers, patients, and the public from measurements, and continuous quality im- and Communication Skills, Professionalism, the range of known chemical, physical, bi- provement, as the medical system evolves to and Systems-Based Practice.) ological, and radiological hazards. (ACGME incorporate such standards of care. core competencies addressed: ACGME Med- Work Fitness and Disability ical Knowledge, Practice-Based Learn- Clinical OEM Management ing and Improvement, Interpersonal and The OEM physician should have the The OEM physician should have the Communication Skills, and Systems-Based knowledge and skills to provide evidence- knowledge and skills to determine whether a Practice.) e22 C 2014 American College of Occupational and Environmental Medicine

Disaster Preparedness and be sensitive to the diverse needs and cul- assist companies in developing, implement- Emergency Management tural backgrounds of those they serve, and ing, or evaluating their occupational health The OEM physician has a critical role anticipate meeting diverse needs in setting or injury management procedures. in emergency preparedness and emergency up their practices. (ACGME core compe- management, with responsibility for protect- tencies addressed: ACGME Practice-Based OEM Population Management ing employed individuals and the national Learning and Improvement, Interpersonal Many OEM physicians serve as cor- workforce from health and economic con- and Communication Skills, Professionalism, porate medical officers or work in aca- sequences of disasters. The OEM physician and Systems-Based Practice.) demic or government settings with respon- should have the knowledge and skills to sibility for employee health. These roles collaborate with the employer management ACOEM OEM CORE require competency in health information team to plan for workplace response to COMPETENCIES KNOWLEDGE management, trend analysis, chronic disease management, and preventive medicine prin- natural or man-made disasters. Emergency AND SKILL SETS management planning includes resource ciples. OEM physicians are often responsi- mobilization, worker population tracking, Clinical OEM ble for disability management programs and communication contingency planning, and The OEM physician should have the employee wellness programs. Clinical com- collaboration with local, state, or federal knowledge and skills to provide evidence- petencies for OEM population management agencies. (ACGME core competencies based clinical evaluation and treatment of in- include understanding health risks, clinical addressed: ACGME Patient Care, Medical juries and illnesses that are occupationally practice guidelines for chronic disease man- Knowledge, Practice-Based Learning and and/or environmentally related. Throughout agement, and current practices in disease de- Improvement, Interpersonal and Communi- the course of care, the physician should seek tection, prevention, and treatment, as well cation Skills, and Systems-Based Practice.) to maximize the patient’s functional recov- as disability management principles. (See ery. Clinical expertise is applied in face-to- ACOEM position statement on Optimizing face care of patients, as well as in activities Health Care Delivery by Integrating Work- Health and Productivity 19 The OEM physician should be able such as case management and peer-to-peer places, Homes, and Communities. ) discussions. (ACGME core competencies ad- to identify and address individual and Clinical—General workplace organizational factors to opti- dressed: ACGME Patient Care, Medical mize the health of the worker and en- Knowledge, Interpersonal and Communica- The OEM physician should provide hance productivity. These issues most often tion Skills, and Professionalism.Alsosee clinical care with an understanding of the 16 include absenteeism, presenteeism, health ACOEM Code of Ethics, and ACOEM posi- workplace, work exposures, and relevant enhancement, and population health man- tion statement on Confidentiality of Medical statutes, such as workers’ compensation. The 18 agement. (ACGME core competencies ad- Information in the Workplace. ) OEM physician should understand and iden- dressed: ACGME Patient Care, Medical tify interactions between personal and occu- Knowledge, Practice-Based Learning and Clinical OEM Care Focus pational health conditions and risk factors. Improvement, Interpersonal and Communi- Physicians practicing in occupa- Core Knowledge and Skills cation Skills, and Systems-Based Practice.) tional health centers, whether free-standing, 1. Obtain appropriately detailed patient his- hospital-based, employer-based, or part of a tories, with an emphasis on occupation Public Health, Surveillance, and network, provide patient care services. They and exposure. Disease Prevention should be competent in performing a careful 2. Identify the potential relationship be- The OEM physician should have the history and physical examination, developing tween patient symptoms and occupa- knowledge and skills to develop, evaluate, and delivering appropriate treatment plans, tional and environmental exposures; ef- and manage medical surveillance programs and managing patients toward functional re- fectively communicate and support an for the workplace, as well as the general covery, while minimizing unnecessary work opinion about work relatedness. public. The physician should be able to ap- disability. Clinical OEM physicians typically 3. Diagnose and treat, or refer and ply primary, secondary, and tertiary preven- provide work injury and illness care, medical manage occupational/environmental ill- tive methods. (ACGME core competencies surveillance examinations, preplacement ex- nesses and injuries with the use of con- addressed: ACGME Patient Care, Medical aminations, fitness-for-duty evaluations, and sultants in related disciplines when indi- Knowledge, Practice-Based Learning and various other clinical services related to spe- cated. Improvement, Interpersonal and Communi- cific work hazards or work fitness ques- 4. Manage a workers’ compensation case cation Skills, Professionalism and Systems- tions. OEM clinicians should have a general treatment plan from first visit to closure, Based Practice.) medicine knowledge base comparable to a including provision of required medi- primary care doctor caring for adult patients, cal documentation, following the rele- OEM-Related Management and because there is a need to manage a wide vant jurisdictional rules. Administration range of conditions both in relation to urgent 5. Identify nonoccupational/environmental The OEM physician should have the care presentations and to determine the im- factors that may contribute to occu- administrative and management knowledge pact of a condition on ability to perform a pational and environmental disease or and skills to plan, design, implement, man- given job. injury. age, and evaluate comprehensive occupa- 6. Elicit patients’ concerns about exposures tional and environmental health programs OEM Clinical Specialist and establish a therapeutic alliance incor- and projects. OEM physicians need an un- The clinical specialist is often engaged porating risk communication. derstanding of health care benefits, workers’ in a focused area of practice, for example, 7. Report all findings to affected individ- compensation systems, and electronic health impairment evaluation, hazardous exposure uals and pertinent information to or- records and knowledge of the laws and reg- evaluation, work capacity evaluation, toxicol- ganizations and employers as appropri- ulations applicable to the jurisdiction, indus- ogy consultation, or workers’ compensation ate (considering medical confidentiality try, and population of interest. OEM physi- case management. OEM clinical specialists issues), advocating for the health and cians in all practice settings are expected to often provide medical/legal consultation and safety of patients and employees.

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8. Work as a team member with other pro- 2. Evaluate a person’s ability to perform ex- Additional Knowledge and Skills fessionals to identify and evaluate oc- ertional work after a cardiac event (such as Board-certified occupational med- cupational or environmental hazards and myocardial infarction, stent/angioplasty, icine specialists and physicians practicing as recommend methods to reduce exposure, arrhythmia, placement of pacemaker OEM clinical specialists should have the fol- mitigate risk, and improve worker health or implantable cardioverter defibrillator, lowing additional knowledge and skills, re- and productivity. coronary artery bypass graft surgery). ferring to dermatologists for assistance as 9. Apply evidence-based clinical practice 3. Apply knowledge of cardiac risk factors clinically indicated: guidelines in one’s practice of medicine. in employee risk assessment and patient (See ACOEM position statement on En- counseling. 1. Diagnose actinic skin damage, as well suring Quality of Care in Workers’ Com- 4. Interpret electrocardiogram for ischemia, as photosensitization dermatitis, includ- pensation Programs: Fair Fee Schedules evidence of infarction, conduction disor- ing cases due to exposure to coal tar, pso- and Evidence-Based Guidelines.20) ders, and arrhythmias. ralens, and polychlorinated biphenyls. 10. Use clinical knowledge to assess impact 2. Diagnose occupational acne, including chloracne. of personal medical conditions on ability Additional Knowledge and Skills to perform work tasks and advise about 3. Differentiate work-aggravated dermato- modifications or accommodations that Some OEM physicians have addi- ses. would permit continued employment. tional knowledge and skills in the follow- 4. Diagnose occupational cutaneous infec- ing area, not considered core for all OEM tions (eg, herpetic whitlows). physicians: Perform cardiovascular evalua- Additional Knowledge and Skills 5. Identify skin neoplasias, especially as tions such as stress testing to assess fitness caused by coal tar, ultraviolet radiation, Some OEM physicians have addi- for duty. hexavalent chromium, or ionizing radia- tional knowledge and skills in the following tion. areas, not considered core for all OEM physi- 6. Diagnose occupational pigmentary disor- cians: Clinical—Dermatology Occupational dermatoses are among ders, including vitiligo. 1. Perform independent medical evaluations. the leading causes of occupational disease in 2. Perform impairment rating examinations the United States. Dermatoses occur also as Some OEM physicians have addi- by using specific sets of guidelines. a result of exposure to hazardous compounds tional knowledge and skills in the following 3. Training and certification for the Na- in the home environment. OEM physicians areas, not considered core for all OEM physi- tional Registry of Certified Medical should provide early recognition, diagno- cians: Examiners—examination of commercial sis, and management of these disorders and 1. Patch testing for diagnosis of allergic con- motor vehicle operators. make necessary recommendations to mini- tact dermatitis and other atopic conditions. 4. Perform Federal Aviation Administration mize their occurrence both in the workplace 2. Skin biopsy. examinations. and at home. 5. Perform specialized evaluations to assess functional capacity. Clinical—Emergency Medicine and Core Knowledge and Skills 6. Review drug tests as an MRO. A list- Surgery ing of more specific competencies of the 1. Differentiate occupational skin disorders by history, examination, and diagnostic OEM physicians should have the MRO can be found at www.mrocc.org/ knowledge and skills to provide acute med- MROComp.pdf. evaluation. i. Diagnose and determine the cause of ical care for a wide variety of common in- allergic contact dermatitis and allergic juries and illnesses, as well as to stabilize and Clinical—Cardiology contact urticaria (and other related Im- refer individuals for emergency care. (See Individuals with underlying cardiac munoglobulin E–mediated allergic re- ACOEM position statement on Automated risk factors and disease may encounter spe- External Defibrillation in the Occupational sponses), particularly those caused by 21 cial concerns in safety-sensitive jobs, while common antigens such as latex, epoxy Setting. ) working around certain chemical agents, and monomer, nickel, and rhus. in performing exertional labor. OEM physi- ii. Diagnose primary irritant-induced der- Core Knowledge and Skills cians engage in primary prevention of car- matoses. 1. Establish emergency procedures and pro- diac disease via involvement in employee iii. Diagnose potentially contagious skin tocols for the clinical management of in- wellness programs and counseling. OEM conditions (varicella/zoster, herpes, dividuals involved in hazardous materi- physicians assist patients, employers, pri- Methicillin-resistant Staphylococcus als incidents, including substance-specific mary care physicians, and cardiologists in aureus, or other skin infections). first aid and medical management proto- the secondary and tertiary prevention of car- 2. Manage occupational and environmental cols. diac disease, as well as the accommodation skin injuries and dermatoses. 2. Recognize and secure appropriate emer- of workers with cardiac concerns. The per- i. Treat and prevent recurrence of contact gency care for life-threatening respiratory, spective of the OEM physician is particu- dermatitis. central nervous system, renal, cardiac, or larly useful in placing workers in special ii. Treat chemical burns, including those other target organ failure, pending the assignments, such as emergency response, caused by caustics, acids, including hy- identification of a specific exposure agent. hazardous waste, commercial driving, fork- drofluoric acid. 3. Diagnose and manage the work-related lift, and respirator use. iii. Manage occupational bullae and cal- implications of surgical conditions and as- luses. sist in safe return-to-work accommoda- Core Knowledge and Skills iv. Prevent and manage solar radiation– tions. 1. Recognize, evaluate, and manage the car- associated skin injury in outdoor work- 4. If working in urgent care setting, perform diac effects of chemical asphyxiants such ers. incision and drainage of abscesses, su- as carbon monoxide, methylene chloride, v. Manage folliculitis barbae in workers turing of simple lacerations, and provide and cyanide. who may be required to shave. other simple wound care. e24 C 2014 American College of Occupational and Environmental Medicine

5. Manage the effects of exposure to physi- Clinical—Infectious Disease imaging or laboratory studies, and the in- cal hazards, including heat, cold, and ra- Blood-borne, waterborne, food-borne, vestigation of occupational risk factors. diation exposure. and airborne pathogens pose unique chal- 2. Select appropriate treatment and man- 6. Understand locally relevant emergency lenges for travelers and in occupational, envi- agement of patients with musculoskeletal preparedness programs and triage con- ronmental, or both settings. Early recognition conditions, using evidence-based guide- cepts. and preventive action, including, when ap- lines. propriate, contact investigations, screening, 3. Identify, manage, and prevent acute and Clinical— Endocrinology prophylaxis, and health risk communication, chronic musculoskeletal disorders and The OEM physician should be aware by the OEM physician can minimize their their associated disabilities, and deter- of the endocrine conditions that can present spread, health effects, and recurrences. mine when such conditions are work- as or complicate work-related conditions or related. Conditions of particular interest interfere with fitness for work, and be able to Core Knowledge and Skills are as follows: select appropriate initial diagnostic tests and 1. The OEM physician should be prepared to i. Spine disorders, including low back manage workplace issues related to common identify, manage, treat, or refer for treat- pain endocrine conditions. ment, and prevent the following: ii. Cumulative trauma disorders, with at- tention to specificity of diagnosis and Core Knowledge and Skills i. Blood-borne, airborne, waterborne, food-borne, and fomite-borne etiology, and both occupational and 1. Consider endocrine conditions (eg, hy- pathogen exposure and associated nonoccupational risk factors pothyroidism and diabetes) that may con- illnesses iii. Joint and extremity injuries and disor- tribute to conditions attributed to work ii. Infestations and zoonotic conditions ders (eg, carpal tunnel syndrome). iii. Transmission risk in food service iv. Degenerative diseases of bones, joints, 2. Manage work fitness decisions related to workers with active infectious dis- and connective tissue related to aging poorly controlled endocrine conditions, eases spread by fecal/oral route 4. Recommend ergonomic interventions or especially diabetes mellitus. 2. Understand and follow recommendations prescribe industrial hygiene/safety evalu- 3. Recognize metabolic syndrome and coun- from public health authorities, such as the ation to evaluate and correct worksite er- sel patients about lifestyle management to US Centers for Disease Control and Pre- gonomic issues. prevent progression to related endocrine vention (CDC) and World Health Organi- 5. Prescribe appropriate rehabilitation ser- and cardiac disease. zation, for immunization of the working vices for an injured worker. 6. Identify delayed recovery and manage Clinical—Gastroenterology populations seen clinically. 3. Apply CDC recommendations for tuber- chronic musculoskeletal pain syndromes. The OEM physician should be able to culosis surveillance and exposure evalu- evaluate abnormal liver function enzymes in ation, including contact investigation and Additional Knowledge and Skills the context of evidence of exposure to work- testing for latent tuberculosis infection. Some OEM physicians have addi- place or environmental toxins, personal risk tional knowledge and skills in the following of such exposure, and as evidence of an un- Additional Knowledge and Skills areas, not considered core for all OEM physi- derlying medical condition for which fitness cians: for duty may be an issue (eg, alcoholism). Some OEM physicians have additional knowledge and skills in the following 1. Joint and other injections. Clinical—Hematology/Oncology areas, not considered core for all OEM physi- 2. Epidural injections. Occupational and environmental ex- cians: 3. Joint aspiration. posures may have potential to cause adverse 1. Sexually transmitted infections. hematological effects or may be carcino- 2. Diseases of travelers. Clinical—Neurology genic. The OEM physician should have the knowledge and skills to evaluate, diagnose, Occupational and environmental ex- and prevent the hematological and carcino- Clinical—Musculoskeletal posures can cause acute and chronic effects genic effects of occupational and environ- Musculoskeletal injuries comprise on the central and peripheral nervous sys- mental exposures. most of the acute occupational injuries seen tems. The OEM physician should have the by the OEM physician and cause major pro- skills and knowledge to evaluate, diagnose, Core Knowledge and Skills ductivity, financial, and human losses for em- and prevent exposure-related neurological 1. Interpret hematological laboratory studies ployees and employers alike. Thorough un- conditions and to facilitate the placement of in the context of medical surveillance and derstanding of the anatomy, physiology, and workers with neurological disorders. postexposure examinations. pathology of the musculoskeletal system, as 2. Perform clinical evaluations to detect the well as appropriate diagnostic and manage- Core Knowledge and Skills health effects of exposure to hematologi- ment skills, is essential. OEM physicians 1. Perform focused neurological and mental cal toxins such as benzene, lead, and ar- should be able to correlate clinical conditions status examinations in the evaluation of sine. with functional capacity in relation to activ- occupational and environmental injuries ities of daily living and work. Applying the or illnesses. Additional Knowledge and Skills principles of epidemiology and ergonomics 2. When indicated, select and utilize the re- Board-certified occupational med- enables the OEM physician to facilitate the sults of neurological and mental status icine specialists and physicians practicing development of programs to prevent these examination procedures or consultations as OEM clinical specialists should have the conditions. in the evaluation of occupational or en- following additional knowledge and skills: vironmental injuries or illnesses, or for Evaluate patients, clinical data, and exposure Core Knowledge and Skills personal neurological conditions that may data to render opinions regarding causation 1. Perform focused and comprehensive mus- be impacting the ability to perform work in cases of suspected occupational or envi- culoskeletal evaluations, including the tasks. Such studies may include imaging, ronmental cancer. history, physical examination, appropriate electrodiagnostic or electrophysiological

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studies, or neuropsychological/neuro- otological conditions (see ACOEM posi- iv. Prescribe physical therapy ap- cognitive testing. tion statement on The Role of the Profes- proaches that emphasize patient 3. Assist specialists, primary care providers, sional Supervisor in the Audiometric Test- movement and participation. and employers in safely returning workers ing Component of Hearing Conservation v. Refer for behavioral counseling, for with neurological conditions to the work- Programs22): example, cognitive behavioral ther- place. i. Identify, clinically manage, and pre- apy, in cases that require addi- vent further injury to individuals with tional emotional support to overcome Clinical—Ophthalmology noise-induced hearing loss. fear/avoidance behavior, disability The OEM physician should have the ii. Evaluate and manage individuals with mindset, or pain catastrophization; clinical and administrative knowledge and external otitis related to, or compli- use therapists familiar with the short- skills to manage occupational eye injuries cated by, the use of hearing protection. term work-focused cognitive behav- and oversee vision screening and protection 3. Interpret an audiogram, identify a stan- ioral therapy approach or other treat- programs. dard threshold shift, and implement ap- ment approaches that help the patient propriate treatment and preventive inter- learn to cope and function better. Core Knowledge and Skills ventions. 3. Follow evidence-based treatment guide- 1. Identify the need for specialized ophthal- 4. Support safety and industrial hygiene pro- lines related to acute opioid prescription mological services and surveillance (eg, fessionals in the design and implemen- and chronic opioid management. Avail- lasers and ethambutol use). tation of hearing conservation programs able resources include the ACOEM Prac- 2. Perform basic eye examination, including and selection of appropriate hearing pro- tice Guidelines and ACOEM’s guidance visual acuity and color/depth tests; use in- tection options for employees. statement Principles for Ensuring the Safe formation from the eye examination to as- Management of Pain Medication Pre- sist in the proper placement of workers. scriptions by Occupational and Environ- Additional Knowledge and Skills 23 3. If working in an urgent care or occupa- Some OEM physicians have addi- mental Medicine Physicians. The fol- tional health clinic setting, OEM physi- tional knowledge and skills in the following lowing concepts are drawn from this state- cians should be able to recognize and treat area, not considered core for all OEM physi- ment and should be familiar to the OEM occupational eye diseases and injuries, re- cians: Perform an audiogram. physician: fer to an ophthalmologist when appropri- Board-certified occupational med- i. Use principles of informed choice ate, and coordinate return to work plan- icine specialists, physicians practicing as with patients before starting opioid ning and needed follow-up. OEM clinical specialists, and OEM popu- therapy. i. Diagnose and manage infectious and lation managers should have the following ii. The provider should set expectations irritant conjunctivitis. additional knowledge and skills: for discontinuation and limit quantity ii. Diagnose and treat ultraviolet photo- to that which is medically appropri- keratitis. 1. Develop, implement, and manage an oc- ate. iii. Identify superficial foreign bodies from cupational hearing conservation program. iii. Recognize the transition point from the eye, and remove or refer for re- 2. Perform hearing loss causation analysis subacute to chronic use and initiate moval. based on review of longitudinal audiomet- chronic opioid treatment guidelines iv. Identify and treat or refer as appropriate ric measurements. (eg, ACOEM) at this point (typically ocular chemical exposures and burns 3. Evaluate and manage patients with 90 days). (including alkali, acid, and hydrofluoric complicated nasopharyngeal conditions iv. The providers should be familiar with acid). caused or aggravated by occupational and and utilize their state’s prescription v. Use fluorescein stain to evaluate the environmental exposure, including vocal drug monitoring program. cornea when indicated. cord dysfunction, laryngeal polyps, neo- v. Set functional goals and assess at ev- plasms, and granulomata. ery visit. If no functional improve- Additional Knowledge and Skills ment, take steps to discontinue opioid Some OEM physicians have addi- Clinical—Pain Management treatment. tional knowledge and skills in the following vi. Appropriately use drug screening for The OEM physician should be famil- drugs of abuse and metabolites of the areas, not considered core for all OEM physi- iar with the issues and pitfalls associated with cians: drug(s) being prescribed. the treatment of various types and presenta- vii. Carefully weigh the risks and benefits 1. Slit lamp examination. tions of pain. of chronic opioid use and set clear 2. Intraocular pressure measurement. rules for their use. Core Knowledge and Skills 4. When referring patients with pain to pain Clinical—Otolaryngology 1. Understand the difference between acute management specialists, collaborate on a The OEM physician should have the and chronic pain, including the neurolog- treatment plan that includes functional clinical knowledge and skills to identify, eval- ical pathways mediating each. restoration and return-to-work planning, uate, diagnose, and manage the care of pa- 2. Use treatment approaches that will help offering concurrent care if the system per- tients with common occupational and envi- patients with pain maintain optimal func- mits. ronmental otolaryngological conditions. tion. i. Establish expectations for working Additional Knowledge and Skills Core Knowledge and Skills within physical limits appropriate for Some OEM physicians have addi- 1. Diagnose and manage nasopharyngeal the diagnosed condition. tional knowledge and skills in the following conditions caused or aggravated by occu- ii. Focus on improved function as the areas, not considered core for all OEM physi- pational and environmental exposure, in- stated goal, rather than pain relief. cians: cluding allergies, rhinitis, or pharyngitis. iii. Prescribe exercise, activities, and 2. Evaluate and manage a patient with hear- work within appropriate limitations 1. Manage chronic opioid therapy. ing loss or other occupationally related as part of the treatment plan. 2. Manage outpatient opioid detoxification. e26 C 2014 American College of Occupational and Environmental Medicine

Clinical—Psychiatry Clinical—Pulmonary ii. Postbronchodilator pulmonary func- The OEM physician should have the With a thorough understanding of tion testing in the assessment of bron- clinical and administrative knowledge and the anatomy, physiology, and pathology of choreactivity skill to recognize, evaluate, and assist in the the respiratory system, the OEM physician iii. Methacholine and specific challenge management or triage of workers with psy- should be able to assess the causes and occu- testing in the assessment of exposure- chological or drug-related problems present- pational impact of respiratory disorders and related bronchoreactivity ing in the workplace, and to identify occu- pulmonary impairment. iv. Exercise tests in the assessment of pational and environmental factors that may pulmonary impairment affect mental hygiene. v. Other pulmonary function testing Core Knowledge and Skills such as measurement of diffusing ca- Core Knowledge and Skills 1. Prevent, identify, diagnose, treat, and/or pacity and lung volumes refer occupational/environmental lung vi. Imaging studies (eg, chest radio- 1. Identify the troubled or psychologically disorders, including the following: graphs, magnetic resonance imaging, impaired employee and manage or refer i. Work-related asthma, including occu- computed tomography) appropriately to community resources, in- pational asthma (eg, toluene diiso- vii. Allergy testing cluding employee assistance programs. cyanate sensitization, exposure to in- 2. Interpret radiograph results reported by a 2. Identify and interpret danger signs of the haled allergens, byssinosis, reactive air- B reader using the International Labour violent, homicidal, or suicidal employee, ways dysfunction syndrome, irritant- Organization system. manage the situation, and refer appropri- induced asthma) and work-exacerbated ately. Participate in the design of violence asthma Some OEM physicians have addi- prevention and response programs. ii. Pneumoconioses (eg, silicosis, coal tional knowledge and skills in the following 3. Diagnose and manage workers who may workers’ pneumoconiosis, asbestosis, area, not considered core for all OEM physi- be under the influence of psychoactive hard-metal disease, benign radio- cians: Perform International Labour Organi- chemicals at work (eg, industrial expo- opaque pneumoconiosis, chronic beryl- zation B readings. sure, medications, recreational drugs, and lium disease) alcohol). iii. Irritant inhalations (eg, acids, alkalis, 4. Support access to psychological care, Clinical—Reproductive Medicine oxides of nitrogen, phosgene, and phos- The OEM physician has the clinical such as work-focused cognitive behavioral phine) therapy, for patients at risk for disabil- knowledge and skill to advise patients about iv. Chronic obstructive pulmonary disease reproductive risks of occupational and envi- ity due to behavioral risk factors, such as v. Hypersensitivity pneumonitis pain catastrophization, disability beliefs, ronmental exposures; the effects of exposure 2. Manage work restrictions and accommo- and work on fertility, pregnancy, and the fe- and fear/avoidance behavior. dations for both occupational and nonoc- 5. Identify and manage the impact of psy- tus; and the ability of the pregnant worker to cupational lung diseases. perform work. chological conditions on ability to work 3. Interpret a spirogram according to Amer- and on the natural history of occupational/ ican Thoracic Society/European Respira- environmental injuries or illnesses (see tory Society standards. Core Knowledge and Skills ACOEM position statement on The Per- 4. If providing spirometry examinations, re- 1. Identify potential adverse reproductive sonal Physician’sRole in Helping Patients fer to the ACOEM position statement on outcomes to both men and women from with Medical Conditions Stay at Work or 24 Spirometry in the Occupational Health chemical, biological, physical, biome- Return to Work ): Setting—2011 Update.25 chanical, and psychological exposures i. Take a psychiatric and psychosocial 5. Perform respirator certification examina- and provide advice to employees and em- history and perform a mental status tions tailored to the anticipated workplace ployers regarding the management of such examination. exposures, to the exertional demands of exposures. ii. Specify restrictions and accommo- the job, and to the type of respiratory pro- 2. Identify and utilize up-to-date sources of dations for employees with psychi- tection used. reproductive toxicology information. atric conditions or taking psychotropic 6. Advise on appropriate respirator options, 3. Recommend appropriate restrictions and medications. in consultation with an industrial hygien- accommodations for pregnant or lactating iii. Identify and treat or refer individu- ist if needed, in consideration of clinical employees. als with psychopathology aggravat- conditions (eg, use of pressure demand ing, presenting as other medical con- respirator in patient with cardiac disease). ditions, or both. Additional Knowledge and Skills Board-certified occupational medi- Additional Knowledge and Skills Additional Knowledge and Skills cine specialists, physicians practicing as OEM clinical specialists, and OEM popu- Board-certified occupational medi- Board-certified occupational med- lation managers should have the following cine specialists and physicians practicing as icine specialists, physicians practicing as additional knowledge and skills: Advise on OEM clinical specialists should have the fol- OEM clinical specialists, and OEM popu- policies and procedures relating to the pro- lowing additional knowledge and skills: lation managers should have the following tection of fertility for both men and women additional knowledge and skills: and for placement of pregnant or lactating 1. For the work-up of occupational or envi- workers. (See ACOEM position statement 1. Identify and assist in the management of ronmental related pulmonary conditions, on Reproductive and Developmental Hazard psychological stressors in the workplace. order or refer for and interpret the appro- Management Guidance.26) 2. Advise managers about the medical liter- priate diagnostic tests, including the fol- ature related to autonomy, flexibility, and lowing: other work management issues that can i. Peak-flow testing and postshift Clinical—Sleep Medicine impact employee productivity, morale, spirometry in the assessment of The OEM physician should recognize and disability. exposure-related bronchoreactivity patients with sleep disorders and be prepared

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to refer for testing and manage the work fit- of Medical Review Officers (MROs) in Regu- 2. Understand and protect patients’ le- ness/safety aspects of this condition. lated and Non-Regulated Drug Testing29). gal rights to confidentiality of medical records information. Core Knowledge and Skills OEM Clinical Specialist 3. Understand the risks of electronic com- 1. Recognize patients at risk for, or having OEM physicians providing specialty munication and apply appropriate con- symptoms of, sleep apnea. services are often tasked with developing trols in communication and recordkeep- i. Refer for testing and diagnosis, and comprehensive hazard control or medical ing. monitor response to treatment. surveillance plans, a task that requires both 4. Maintain complete, timely, and legible ii. Manage the work fitness aspects, es- breadth and depth of industrial and regula- records. pecially safety considerations if in a tory knowledge and an understanding of pre- 5. Recognize and address ethical dilem- safety-sensitive position. ventive medicine principles. When evaluat- mas in the practice of OEM, using rel- iii. Understand the system implications of ing a particular clinical or workplace issue, evant guidelines, such as those from this diagnosis, for example, in the mil- the OEM clinical specialist needs to be able ACOEM, the Association of Occupa- itary disability evaluation system. to research details, analyze applications to tional and Environmental Clinics, the 2. Prevent, manage, and recognize circadian the specific clinical situation, and synthesize International Commission on Occupa- dysrhythmias, such as shiftwork sleep dis- and effectively communicate a rationalized tional Health, and the American Medical orders and those associated with trans- opinion. The OEM clinical specialist often Association. Educate employers, clients, meridian travel over multiple time zones; provides medicolegal services that require an attorneys, employees, and their represen- provide appropriate recommendations to in-depth knowledge of expert witness princi- tatives on the ethical issues and the codes the patient and the employer (see ACOEM ples such as Daubert. that apply to the practice of OEM. guidance document on Fatigue Risk Man- 6. If providing workers’ compensation– agement in the Workplace.27) OEM Population Management related care, comply with requirements of the relevant statute, including comple- The OEM population manager should tion of the required forms and coopera- OEM-Related Law understand health care and health insurance tion with case management and return- systems and the relevant laws and regula- and Regulations to-work planning. tions, including the Affordable Care Act. The OEM physician should have the 7. Report cases of occupational injury, ill- As advisors to the government, corporations, knowledge and skills necessary to comply ness, and/or death according to existing or other organizations, the OEM physician with regulations important to occupational regulations. needs to understand how to measure and an- and environmental health, as well as the wide 8. Balance ethical principles applicable to alyze trends related to illness or work injury, range of laws and regulations related to the individual patient care to those that ap- as well as develop and implement employee interactions between work and health. As ply to addressing population health con- wellness programs in compliance with ap- recognized experts on issues relating to the cerns, for example, the need to report a plicable laws. This OEM role also includes causation of occupational and environmental hazard that may impact others, against advising on policies and procedures related injuries and illnesses, as well as having the the wishes of an affected patient. to specific populations of workers in relation ability to perform work with or without rea- 9. Respond appropriately to impairment in to health conditions, for example, immuniza- sonable accommodations, OEM physicians self and other health care professionals. tion policies and medical removal require- are frequently called on to provide expert tes- 10. Comply with and explain consensus ments. timony, write expert opinion reports, and pro- standards applicable to specific groups vide peer review. The OEM physician needs of employees, for example, the NFPA to interact knowledgeably with other medical Core Knowledge and Skills 1582: Standard on Comprehensive Oc- professionals and nonmedical professionals, 1. Comply with and explain applicable reg- cupational Medical Program for Fire including human resources managers, oper- ulations, as well as their interpretation Departments, and the ACOEM Guidance ations managers, safety professionals, union and enforcement, in relation to occupa- for the Medical Evaluation of Law En- leaders, government officials, and legal pro- tional health practice, to employers, em- forcement Officers (LEOs).33 fessionals, and should understand the rules ployees, and patients. These include the of these worlds. (ACGME core competencies following: Additional Knowledge and Skills addressed: Practice-Based Learning and Im- i. Occupational Safety and Health Ad- Board-certified occupational med- provement, Interpersonal and Communica- ministration (OSHA) standards and icine specialists, physicians practicing as tion Skills, Professionalism, and Systems- regulations, including the General OEM clinical specialists, and OEM popu- Based Practice.) Duty Clause. lation managers should have the following ii. Federal Motor Carrier Safety Admin- additional knowledge and skills: Clinical OEM Care Focus istration standards for medical fit- The clinical OEM physician should be ness. 1. Comply with and explain applicable regu- familiar with the laws and regulations related iii. Department of Transportation, Fed- lations, as well as their interpretation and to the local workers’ compensation jurisdic- eral Railroad Administration, Federal enforcement, in relation to occupational tion, as well as those governing the delivery Aviation Administration, and other health practice, to employers, employees, of OEM medical services, for example, the transportation-related regulations re- and patients. These include the following: examination for commercial drivers, MRO garding fitness in safety-sensitive po- i. Legislation and regulations protect- requirements for urine drug testing, medi- sitions where employee health prob- ing the employment rights of persons cal surveillance standards related to the work lems may endanger others. with disabilities (eg, the Americans hazards for which such examinations are pro- iv. The privacy provisions of the Health with Disabilities Act [ADA], the ADA vided, as well as the rules related to pa- Insurance Portability and Account- Amendment Act, and the Rehabilita- tient confidentiality and recordkeeping. (See ability Act, including exceptions re- tion Act of 1973) ACOEM position statements on Ethical As- lated to workers’ compensation and ii. The Genetic Information Nondiscrim- pects of Drug Testing28 and Qualifications public safety. ination Act (see ACOEM guidance e28 C 2014 American College of Occupational and Environmental Medicine

document on Genetic Screening in the tal problems is the knowledge of when lab- iv. Household chemicals Workplace30) oratory tests and treatment approaches (eg, v. Ionizing and nonionizing radiation, in- iii. The Family Medical Leave Act chelation therapy) can be misleading or even cluding radon iv. Environmental health and safety regu- harmful to conduct. The OEM role includes vi. Ultraviolet radiation lations knowledge of governmental agencies and pri- 4. Explain the psychological effects asso- v. The rules related to the various ju- vate resources to assist the patient in environ- ciated with acute or chronic exposure risdictions in which OEM work is mental monitoring and mitigation. to actual or perceived environmental done (workers’ compensation, veter- hazards. ans’ benefits, military disability eval- OEM Clinical Specialist uation, etc) OEM clinical specialists should have Additional Knowledge and Skills 2. Respond in compliance with the require- a broad knowledge of common contaminants Board-certified occupational medi- ments of employee/community right-to- of all environmental media indoors and out- cine specialists, physicians practicing as know regulations and advise individuals doors and how to assess exposure to these OEM clinical specialists, and OEM popu- about their rights to access information. contaminants. They should have the skills lation managers should have the following to characterize and communicate risk to pa- Some OEM physicians have addi- additional knowledge and skills: tients for any environmental contaminant, us- tional knowledge and skills in the following ing published data. Clinically, they should be 1. Understand when to obtain environmental areas, not considered core for all OEM physi- knowledgeable about the appropriate appli- monitoring. cians: cation and interpretation of environmental 2. Interpret and explain the results of envi- 1. Provide medical–legal reports and expert and biological monitoring for any environ- ronmental monitoring. opinions and testimony on OEM issues. mental contaminant, as well as environmen- 3. Identify and manage individual health ef- 2. Participate in the rule-making process by tal epidemiology and toxicology studies and fects associated with air, water, or ground participating in committees or working health risk assessment. Clinical specialists contamination by natural or artificial pol- groups, providing testimony, or other ac- should understand basic principles of envi- lutants. tivities for sharing OEM expertise with ronmental mitigation and should be skilled 4. Identify and manage population exposure the decision makers. in the management of clinical disease states to environmental toxins (eg, heavy metals, where treatments specific to an exposure are solvents, pesticides, asbestos, silica, car- Environmental Health relevant. bon monoxide, hydrogen sulfide, dioxin, The OEM physician should have the and polychlorinated biphenyls). knowledge and skills necessary to recognize OEM Population Management 5. Identify and manage concerns about the potential chemical, physical, and biological The OEM physician should have a health effects of human exposure to environmental causes of health concern to the firm grasp of environmental epidemiology, contaminated water, sewage, and human individual, as well as to community health. including the interpretation and design of waste. Environmental issues most often include air, epidemiological studies in collaboration with 6. Advise individuals and communities water, or ground contamination by natural other environmental health disciplines. In about the reproductive implications of en- or artificial pollutants. The physician should managing the environmental health of pop- vironmental exposure. know about the health effects of the broad ulations, the practitioner should be able to physical and social environment, which in- interpret published quantitative risk assess- Work Fitness and Disability cludes housing, urban development, land use ments and the principles of comparative, cu- Management and transportation, industry, and agriculture. mulative, and integrated risk assessment, and The OEM physician should have the (ACGME core competencies addressed: Pa- understand their limitations. The physician knowledge and skills to determine whether a tient Care, Medical Knowledge, Interper- should be skilled in designing and deliver- worker can safely be at work and complete sonal and Communication Skills, Profession- ing risk communication to populations. The required job tasks. The physician should be alism, and Systems-Based Practice.) OEM population manager should use the ba- able to assist the patient in identifying per- sic scientific tools of toxicology, risk assess- sonal functional goals and develop a treat- Clinical OEM Care Focus ment, and environmental epidemiology to ment or management plan that attempts to The OEM physician should be com- provide evidence-based input to the creation align the patient’s goals with the job require- petent in taking an exposure history that in- of environmental policy in both the private ments. The physician should have the knowl- cludes environmental as well as occupational and public sector. Finally, this practitioner edge and skills necessary to provide guidance sources. The physician should have a basic should have a deep understanding of risk per- to the employee and employer when there is understanding of not only environmental haz- ception, acceptable risk, and environmental a need for integration of an employee with a ard identification but also how to characterize justice as key social sciences fundamental to disability into the workplace or when there risk on the basis of an assessment of expo- the practice of environmental health for pop- is a need to pursue other avenues such as sure, including potential routes of exposure ulations. vocational rehabilitation or disability bene- and whether a completed pathway of expo- fits. (ACGME core competencies addressed: sure has occurred. Providers should possess Core Knowledge and Skills Patient Care, Medical Knowledge, Interper- the knowledge of dose–response and how 1. Identify sources and routes of environ- sonal and Communication Skills, Profession- to compare environmental and biomonitor- mental exposure and recommend methods alism, and Systems-Based Practice.) (See ing data to published standards. Clinicians of reducing environmental health risks. ACOEM position statement on Ensuring should be aware of the approach to clin- 2. Recognize common illnesses that may be Quality of Care in Workers’ Compensation ical and exposure assessment of common impacted by environmental exposures. Programs: Fair Fee Schedule and Evidence- clinically significant environmental agents 3. Effectively communicate risk from vari- Based Guidelines.20) and diseases relevant to the geographic area ous exposures: where they practice, such as lead, asbestos, i. Indoor and outdoor air pollution Clinical OEM Care Focus arsenic, and radon. As important as know- ii. Water pollution The clinical OEM physician should ing how to evaluate common environmen- iii. Hazardous waste collect a comprehensive history from the

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patient, obtain additional information from als with disabilities due to either work-related iv. ACOEM Guidance for the Medical the employer, other providers, and other injuries or underlying personal morbidities. Evaluation of Law Enforcement Offi- professionals such as ergonomists, perform The physician should be able to design pre- cers (LEOs).33 hands-on physical examination, and may or- ventive interventions on the basis of tracking der laboratory testing as clinically indicated. and review of data on injury occurrences and Additional Knowledge and Skills The physician then integrates this data to outcomes. The physician may develop pro- Board-certified occupational medi- define physical and mental impairment in grams, such as transitional work or placement cine specialists, physicians practicing as specific terms. On the basis of the worker’s programs, to enable those with temporary and OEM clinical specialists, and OEM popu- impairment, and knowledge about the essen- permanent disabilities to be placed in produc- lation managers should have the following tial functions of the job, the OEM physi- tive positions within an organization. Physi- additional knowledge and skills: cian should determine the worker’s ability to cians engaged in population management are 1. Design and implement integrated systems perform specified job tasks with or without also often called on to evaluate the effective- of work disability prevention and manage- accommodations. The OEM clinical physi- ness of OEM medical care delivered by other ment: cian communicates practical work restric- physicians, and monitor adherence to clini- i. Design systems to identify and man- tions and recommends reasonable accommo- cal practice guidelines, as well as outcomes, age the impact of psychological con- dations that maximize the worker’s ability to such as lost work days and the effects of pre- ditions, substance abuse, and family remain safely productive. The OEM clinician senteeism. stresses on the natural history of ill- should be familiar with the behavioral risk ness and injury. factors underlying work disability and under- ii. Design and implement protocols stand how to mitigate these risks. Physicians Core Knowledge and Skills for preplacement, stay-at-work, and in this role should be familiar with chronic 1. Integrate work disability prevention and return-to-work for patients with work- pain management treatment guidelines and management principles into delivery of related or personal medical condi- prepared to treat, evaluate, or manage cases clinical care. tions. complicated by chronic pain according to 2. Establish clinical treatment protocols that iii. Develop preventive maintenance evidence-based guidelines. These physicians include the following: plans for employees who have recov- should be prepared to engage in case manage- i. Early identification of the employee at ered from work injuries and track ment, including coordination of referrals for risk for delayed recovery. compliance. needed care with other specialists, while con- ii. Use of evidence-based guidelines in 2. Design and implement protocols to evalu- tinuing to manage the return-to-work/stay-at- diagnosis and treatment. ate prospective and current employees for work planning. iii. Tracking progress against prognostic conditions creating an undue risk to self indicators. or others in the workplace, in compliance iv. Identification and management of de- OEM Clinical Specialist with the ADA and the ADA Amendment layed recovery. The OEM clinical specialist engaged Act, and consistent with the regulations v. Communicating recommendations for in work fitness evaluation should have the and standards of the applicable system temporary (transitional work) or per- skills to perform independent medical dis- of evaluation (eg, workers’ compensation, manent accommodations for disabled ability evaluations, rate impairment, and very Federal Motor Carrier Safety Administra- workers. clearly communicate disability for the pur- tion, National Fire Protection Association, 3. Explain and make clinical decisions, as poses of job placement and disability com- etc). well as placement/accommodation recom- pensation. OEM specialists are often called mendations relating to the concept of “di- Some OEM physicians have addi- on to evaluate patients whose recovery, return rect threat” as defined under the ADA, tional knowledge and skills in the follow- to work, or fitness for work are complicated and reconcile these decisions with public ing areas, not considered core for all OEM by the use of controlled substances. In such safety considerations as defined by other physicians: Assess and express impairment cases, the OEM clinical specialist is expected systems. in terms required by the relevant legal or to perform or facilitate appropriate testing 4. Translate impairment assessments into benefit systems—for example, the American and referral to appropriate specialists for safe work functional capacity statements Medical Association Guides to the Evalua- definitive care, and support needed follow- for the use of employers in placing em- tion of Permanent Impairment.34 up monitoring on return to the workplace. ployees in jobs. The specialist may also be called on to eval- 5. Conduct evaluations to determine fitness Toxicology uate a worker’s fitness for duty in the face of for duty in compliance with applicable The OEM physician should have the certain environmental hazards such as toxic regulations in reference to specific work knowledge and skills to recognize, evalu- chemical exposure or physical hazards (eg, exposures, work tasks, or public safety ate, and treat health effects of exposures to heat stress and radiation). The OEM clinical concerns. toxic agents at work or in the general en- specialist is expected to be able to evaluate 6. Address employment concerns for pa- vironment. The physician also should have how health problems might be impacted by tients with identified temporary or perma- the knowledge and skill to develop, evaluate, such environmental conditions and should be nent medical conditions. and manage medical surveillance and bio- able to specify restrictions or recommend rea- 7. Refer to the ACOEM position statements logical monitoring programs for toxicologi- sonable accommodations to keep the worker relevant to this topic: cal exposures. (ACGME core competencies safely productive in their job or if necessary, i. A Guide to High Value Physician addressed: Patient Care, Medical Knowl- an alternate placement. Services in Workers’ Compensation31 edge, Practice-Based Learning and Improve- (published with IAIABC). ment, Professionalism, and Systems-Based OEM Population Management ii. The Personal Physician’sRole in Help- Practice.) The OEM physician in the role of man- ing Patients with Medical Conditions aging populations may be called on to estab- Stay at Work or Return to Work.24 Clinical OEM Care Focus lish policies and procedures or design sys- iii. Preventing Needless Work Disability OEM physicians involved in clinical tems to facilitate the employment of individu- by Helping People Stay Employed.32 care should be familiar with and able to e30 C 2014 American College of Occupational and Environmental Medicine

use existing resources and databases—for ex- industrial hygiene records and review and in- OEM clinical specialists should have the fol- ample, safety data sheets (SDS), hazardous terpretation of the toxicology literature. lowing additional knowledge and skills: substances data bank, threshold limit val- ues (TLVs), etc—to characterize the poten- OEM Population Management tial risk from occupational and environmental OEM physicians who practice popula- 1. Evaluate, treat, and/or properly refer per- chemical exposures. These physicians should tion management should be prepared to guide sons whose health may be affected by also be able to interpret industrial hygiene re- policies to ensure that appropriate workplace acute or chronic contact with occupa- ports and other data describing specific expo- health surveillance and monitoring programs tional and environmental chemicals: sure conditions to determine potential routes are developed and implemented for work- i. Identify the likely toxic exposure on of exposure and the likely doses received by place chemicals. They should also be able the basis of clinical signs and symp- specific patients to determine possible over- to analyze surveillance and monitoring re- toms. exposure. They should be familiar with the sults to identify workplace chemical haz- ii. Identify chronic health effects (eg, adverse effects of such overexposures on the ards and evaluate changes over time. These hepatotoxicity, asthma, central and exposed individuals, as well as the standard OEM physicians should participate in re- peripheral nervous system toxic- clinical and biological tests used to confirm view of ongoing industrial hygiene programs ity, and interstitial fibrosis) resulting such adverse effects. They should be familiar to determine their appropriateness and ad- from toxic exposure and obtain nec- with and able to implement standard com- equacy, and also to ensure that workplace essary confirmatory testing. Manage ponents of medical surveillance and biologi- toxicological hazards are identified and ad- medical care and secondary preven- cal monitoring appropriate for individuals ex- dressed. They should also be prepared to tive measures for individuals chron- posed to specific chemicals. They should also review and determine the appropriateness ically affected by toxic exposure. have knowledge of specific legally mandated and adequacy of chemical-related workplace 2. Determine whether a person has a health (eg, OSHA) surveillance and monitoring pro- safety programs—for example, selection and condition that increases risk from the ef- cedures for those chemicals. These OEM use of respirators and personal protective fects of exposure to chemical agents. physicians should also understand when to equipment (PPE). OEM researchers are of- 3. Distinguish health effects of exposure to refer exposed patients for specialist assess- ten involved in studying and reporting on chemicals from other sources. ment and care, how to comply with legally the impact of specific toxins in population 4. Determine the nature and extent of po- mandated reporting requirements, and how groups. OEM physicians are critical mem- tential occupational and environmental to properly inform employers when workers bers of public health care agencies responsi- chemical exposures, considering routes have suffered work-related toxicological dis- ble for establishing laws and regulations for of exposure and routes of absorption: orders. protecting workers and the public from toxi- i. Use appropriate written and comput- cological hazards. Risk communication is an erized databases to identify the haz- important skill for the OEM physician prac- ardous ingredients and toxicological OEM Clinical Specialist ticing population management related to tox- properties of chemical agents. OEM physicians who practice toxi- icology. ii. Identify the physical characteris- cology as a clinical subspecialty should be tics of hazardous agents (eg, liq- knowledgeable about chemical toxicities in Core Knowledge and Skills uid/gas/vapor/particulate, molecular general and be able to evaluate patients on 1. Understand the potential toxicity, includ- weight, and vapor pressure) and their the basis of their clinical presentation, rather ing medical surveillance requirements and impact on the potential for exposure. than exclusively relying on foreknowledge protection standards related to materi- iii. Estimate the likely degree of absorp- of the specific chemicals to which individual als used by working populations rou- tion on the basis of circumstances of patients were exposed. They should be able tinely served clinically (eg, preplace- exposure, considering factors such as to develop comprehensive differential diag- ment/surveillance examinations). the nature of the substance, the route noses, including toxicological and nontoxi- 2. Obtain information about hazardous ma- of exposure, concomitant exposures, cological etiologies. This requires that they terials implicated or suspected in toxic ex- and characteristics of the patient (eg, be able to perform technical literature re- posure evaluations (eg, from SDS). age, susceptibility factors, and any views, interpret the toxicology literature, and 3. Use available information from the pa- PPE used). use the principles of toxicokinetics, risk as- tient, employer, and emergency respon- 5. Detect, insofar as possible, preclinical or sessment, and health risk communication to ders, and information sources such as clinical effects arising from chemical ex- provide specialized guidance and treatment SDS, incorporating information about posure and implement appropriate pre- to individual patients. These OEM physicians protective equipment used, to character- ventive measures: should be knowledgeable about the preclini- ize risk of exposure, absorption, and toxic i. Identify, obtain, and evaluate cal effects of exposures, the potential effects effects. biomarkers or other tests to assess and interactions of chemical mixtures, and 4. Order clinically appropriate laboratory exposure and/or health effects, when the contribution of individual susceptibility studies to determine acute organ or appropriate, including biological (eg, age, diet, and chronic diseases) to ad- metabolic effects. monitoring techniques that assay the verse toxicological effects. They should be 5. Determine need for referral for specialty substance, its metabolites, or other able to manage medical care and secondary evaluation. indices. prevention for individual patients, and they 6. Recognize conditions that may be sen- ii. Identify clinical or biochemical evi- should be knowledgeable about advanced tinel events associated with toxic expo- dence of target organ damage when diagnostic and therapeutic modalities. The sures and take appropriate action to pro- exposure hazard is recognized. OEM clinical specialist should also provide tect the health of others who may be ex- iii. Identify chronic health effects (eg, guidance to chemical-using employers and posed. hepatotoxicity, asthma, central and others regarding employment and production peripheral nervous system toxic- decision-making, including chemical selec- Additional Knowledge and Skills ity, and interstitial fibrosis) resulting tion and appropriate controls; this may in- Board-certified occupational med- from toxic exposure and obtain nec- clude review and interpretation of workplace icine specialists and physicians practicing as essary confirmatory testing.

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6. Assess clinical, worksite, and environ- thoroughly acquainted with the regulatory re- and appropriately seeks professional consul- mental data, along with literature reviews quirements and potential health effects of the tation from qualified individuals to evaluate in the performance of patient evalua- work hazards for which they offer surveil- and/or quantify such exposures. The OEM tions. lance examinations (eg, noise, asbestos, and clinical specialist interprets clinical find- 7. Obtain and interpret detailed exposure lead). In addition, the OEM clinician will ings and specific directed laboratory anal- information, including exposure histo- be called on to evaluate patients who re- yses, and industrial hygiene/safety data to ries, SDS, industrial hygiene reports, and port symptoms they attribute to work expo- evaluate health threats related to the iden- other data. sures, for example, headaches after breath- tified hazard. The OEM clinical specialist 8. Evaluate the severity of exposure to ing fumes. The OEM clinician should have has knowledge of the workplace or environ- hazardous agents, considering dose– a working knowledge of the health effects mental conditions, often supported by vis- response relationships. of commonly used chemicals such as sol- its to the workplace, which supports proper 9. Interpret exposure data in the context of vents and cleaning agents. The physician ob- prescription of activity or exposure limita- the scientific literature (human and ani- tains a relevant history, including exposure tions and work disposition. The OEM clini- mal) and the patient’s presentation. history and information about controls such cal specialist applies knowledge of the var- 10. Understand, explain, and be able to ap- as PPE, performs appropriate physical ex- ious occupational and/or environmental ex- ply toxicokinetic data (including routes amination, and judiciously orders laboratory posure levels—such as permissible exposure of exposure, absorption, metabolism, studies or recommends environmental mea- limits, TLVs/biologic exposure indices, rec- storage, and excretion) to clinical and surements to help characterize the risk. ommended exposure limits, Workplace Envi- employment-related decision-making. The OEM patient care clinician is not ronmental Exposure LevelsR , acute exposure 11. Conduct a literature search to research usually a toxicologist but should be prepared guideline levels, minimal risk levels, etc— the health effects of a chemical substance to synthesize the clinical information in rela- used to control or correlate exposure and ef- when more information is needed. tion to information about exposure to various fects, with a firm grasp of their applications 12. Interpret and apply information from chemical, physical, biological, ergonomic, and limitations. The OEM clinical special- medical, toxicological, and environmen- and psychological hazards (stressors). The ist identifies populations or subpopulations tal health literature. clinical OEM physician should be able to de- of individuals with occupational or environ- 13. Perform complex causation analysis velop a differential diagnosis and properly mental exposures that place them at a calcula- and provide a rationalized and well- attribute and make recommendations related ble risk of untoward effects, to modify or con- supported written report. to the amelioration of the identified hazards. trol exposures and develop a plan for medical 14. Effectively communicate risk, necessary The clinician should also determine the suit- surveillance, which is sometimes delineated actions, and reassurance to patients. ability for continued work in a given occupa- by regulations governing specific exposures. tional setting and address the need for spe- Hazard Recognition, Evaluation, cific control measures (such as PPE). The OEM Population Management and Control physician practicing OEM should be able to OEM physicians who focus on popula- The OEM physician should have the develop a treatment plan that incorporates tion management should be aware of the reg- knowledge and skills necessary to assess medical care, exposure control, and work rec- ulatory requirements for the evaluation and whether there is risk of an adverse event ommendations on the basis of data (includ- quantification of exposures in the workplace from exposure to physical, chemical, bio- ing position description, “job analysis,” or or environment, to identify individuals at risk logic, ergonomic, or psychological hazards both). This physician plays a role in educat- of untoward exposure and possible place- in the workplace or environment. The OEM ing both the patient and the employer about ment in a medical monitoring program. Such physician should be prepared to collaborate the exposures and the methods necessary to physicians understand the breadth of chemi- with industrial hygienists or other qualified control such exposures. The OEM clinician cal, physical, biological, ergonomic, and psy- safety and health care professionals and in- should be aware of regulatory requirements chological hazards (stressors) in individu- terpret measurements and reports from such for the evaluation and quantification of the als that arise in the workplace or environ- professionals in context. If there is a risk workplace or environment to identify indi- ment of interest. Upon the basis of identifica- with exposure, then that risk can be char- viduals at risk of untoward exposure. The tion and exposure assessments performed by acterized with recommendations for control physician practicing OEM should be able to qualified safety and health care profession- measures or medical surveillance. The OEM determine when to consult a board-certified als, the OEM population manager orches- physician should demonstrate an understand- OEM physician or other qualified occupa- trates the development of appropriate plans ing of the core principles of industrial hy- tional safety and health care expert when spe- for medical surveillance parameters for pre- giene, ergonomics, occupational safety and cific knowledge or information is not held by placement, baseline, periodic, and termina- risk/hazard control, and communication, and the examining physician. tion monitoring. These physicians work with apply the principles of the Hierarchy of Con- human resources departments to ensure that trols to protect the health of individual work- OEM Clinical Specialist current and complete position descriptions, ers, patients, and the public from the range The OEM clinical specialist has the job analyses, or both are available for all of known chemical, physical, biological, and knowledge and skill to obtain a complete and employees. The OEM physician-director is radiological hazards. (ACGME core com- comprehensive history and perform a physi- able to evaluate the results of workplace or petencies addressed: Medical Knowledge, cal examination focused on effects of expo- environmental assessment(s) as applied to Practice-Based Learning and Improvement, sure, or physical requirements of an occu- the maintenance of health in such individ- Interpersonal and Communication Skills, pation or task (using a position description uals to ensure continued health and produc- and Systems-Based Practice.) or job analysis), and available or requested tivity, and direct, allocate, and appropriately exposure assessment data. The OEM clini- conserve personnel and fiscal resources. The Clinical OEM Care Focus cal specialist is familiar with the untoward OEM physician-director should be able to un- The clinical OEM physician is often effects of chemical, physical, biological, er- derstand the epidemiological methods used engaged in providing medical surveillance gonomic, and psychological hazards (stres- to evaluate population trends in monitored examinations, which relate to specific work sors) to individuals that can arise in a spe- individuals and ensure the maintenance of hazards. Physicians in this role should be cific workplace or environmental situation health in the monitored population. The OEM e32 C 2014 American College of Occupational and Environmental Medicine

physician-director should take the lead in the i. Identify and minimize exposure to need for PPE and other exposure control management of the complete and compre- ionizing radiation (eg, radon, radio- methods: hensive program by ensuring the competency graphs, and radioisotopes). i. Identify and control occupational/ of all individuals involved in the assessment ii. Identify and minimize exposure to environmental risk factors for the de- and control of exposure(s) in the workplace; nonionizing radiation (eg, ultraviolet, velopment of skin disorders. proper medical evaluation and clinical man- infrared, microwave, radiofrequency, ii. Assess the workplace for potential agement of exposed or monitored individu- and extremely low-frequency electro- hazards to the eye and address issues als (to include the use of PPE, administrative magnetic fields). of eye protection, including the use controls such as activity/exposure/work limi- iii. Collaborate with appropriate health of safety glasses and contact lenses. tations); coordination of the contributions of care and safety personnel, including iii. Describe the key elements of a good professional personnel involved with expo- industrial hygienists, safety special- respirator program. sure prevention or amelioration; and direc- ists, radiation protection officers, and iv. Identify the visual requirements for tion of the overall OEM program to ensure health physicists. various occupations (including reg- protection and best utilization of the most iv. Prevent, diagnose, and manage health ulatory requirements) and correlate important asset—people. effects associated with high-altitude these requirements with job tasks and living and working. job hazards in determining fitness for v. Explain the hazards of barotrauma duty and accommodations. Core Knowledge and Skills and decompression sickness. 1. Recognize common occupational hazards 6. Design and manage a hearing conserva- and appropriate control measures, includ- Disaster Preparedness and tion program for workers exposed to loud Emergency Management ing PPE. noise. (See ACOEM guidance document The OEM physician has a critical role 2. Understand protective measures appropri- on Occupational Noise-Induced Hearing in emergency preparedness and emergency ate for the hazards of interest in the work- Loss35): management, with responsibility for protecting populations served. i. Advise employees and employers re- ing employed individuals and the national 3. Communicate concerns related to health garding the use of hearing protection. workforce from health and economic con- hazards to appropriate employer health ii. Design programs to comply with the sequences of disasters. The OEM physician and safety professionals; participate in OSHA noise standard. should have the knowledge and skills to mitigation efforts. 7. Assist employees and employers with the collaborate with the employer management management of the effects of shiftwork, team to plan for workplace response to jet lag, and other chronobiological stres- Additional Knowledge and Skills natural or man-made disasters. Emergency sors. Board-certified occupational medi- management planning includes resource 8. Perform a risk assessment: cine specialists, physicians practicing as mobilization, worker population tracking, i. Explain the basic methodology of risk OEM clinical specialists, and OEM popu- communication contingency planning, and assessment. lation managers should have the following collaboration with local, state, or federal ii. Identify exposure-related health haz- additional knowledge and skills: agencies. (ACGME core competencies ad- ards. dressed: Patient Care, Medical Knowledge, iii. Assess dose–response relationships. 1. Characterize existing and potential oc- Practice-Based Learning and Improvement, iv. Evaluate levels of exposure. cupational and environmental hazards Interpersonal and Communication Skills, v. Characterize risk. within defined populations: and Systems-Based Practice.) i. Perform a workplace walk-through 9. Communicate to target groups, includ- assessment of occupational health ing health care professionals, patients, and safety concerns. the public, and the media, in a clear and Clinical OEM Care Focus ii. Perform an environmental site visit. effective manner both orally and in writ- The specialized dual knowledge of the 2. Evaluate and interpret the results of in- ing, the levels of risk from real or po- workplace and medicine offers OEM physi- dustrial hygiene surveys. tential hazards and the rationale for se- cians a unique role in disaster preparation 3. Interpret and apply OSHA-permissible lected interventions. Prepare and deliver and response. In planning phases, OEM clin- exposure limits, the American Confer- a basic hazard/risk presentation. Man- icians providing patient care services evalu- ence of Governmental Industrial Hygien- age ad hoc risk communication (eg, town ate workers with first response responsibil- ists TLVs and biological exposure in- hall meetings) and reactions to situations ities for fitness for such duties. Physicians dices, Environmental Protection Agency such as: apply knowledge of personal protection and standards, and other criteria in the as- i. A perceived or actual cluster of dis- other applied approaches to health protection sessment of chemical and physical haz- ease. and have the skills to evaluate the adequacy ard exposures. ii. An episode of mass psychogenic ill- of protection at the individual level. OEM 4. Apply ergonomic principles to optimize ness. clinicians should be able to describe specific comfort and reduce risk at work, includ- iii. Widespread exposure or perceived threats, including a broad range of chemical, ing evaluation and redesign of hazardous exposure to toxic materials. biological, radiological, nuclear, and physi- lifting jobs, repetitive motion work, and iv. Communities affected by pesticide cal hazards. OEM clinicians are expected to jobs with special visual demands. applications, hazardous waste sites, be cognizant of clinical features that suggest 5. Advise employers and employees regard- transportation accidents, and other exposure to biological, chemical, or radio- ing industrial hygiene controls, such as environmental and industrial expo- logical weapons and handle these as sentinel work practices, respirator use, and en- sures. events with appropriate notification of au- gineering controls. Recommend and im- v. The controversies associated with thorities. OEM clinicians are also expected to plement policies and control measures electromagnetic field exposure. participate in emergency clinical care, which to reduce or mitigate safety and health 10. Assess the workplace and environment may include triage, first aid services, and de- hazards: for potential hazards and address the livery of basic emergency medical care.

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OEM Clinical Specialist 4. Recognize sentinel events that may repre- ment, employee wellness programs, and pop- The OEM specialist may be called on sent a potential disaster or epidemic. ulation health management. (ACGME core to respond to threats from intentional assaults 5. Understand local clinical role in the com- competencies addressed: Patient Care, Med- (including terrorism), unintentional incidents munity emergency/disaster response plan. ical Knowledge, Practice-Based Learning that may result in mass casualties, infectious and Improvement, Interpersonal and Com- disease outbreaks and pandemics, and natural Additional Knowledge and Skills munication Skills, and Systems-Based Prac- disasters. The knowledge base of the special- Board-certified occupational medi- tice.) ist includes detailed knowledge of the haz- cine specialists, physicians practicing as ards specific to those industries included in OEM clinical specialists, and OEM popu- Clinical OEM Care Focus the physician’s practice. The physician uses a lation managers should have the following The OEM clinician providing clinical systematic approach to monitoring and pro- additional knowledge and skills: patient care services may be involved in im- tecting the health of populations, as well as plementing health screenings and coaching the health of individual workers and other 1. Describe specific threats, including a individuals about behaviors that will improve persons at risk. A working knowledge of broad range of chemical, biological, ra- their health. Screening measurements may regulations, regulatory compliance, and the diological, and physical hazards. include not only formal health risk assess- structure of government agencies responsible 2. Apply knowledge of personal protection ments or biometric screenings but also infor- for health protection at most relevant levels and other approaches to health protection mal assessment of health risk, such as asking is imperative. The specialist has expertise in to evaluate the adequacy of protection at about smoking, nutrition, and exercise during evaluating workplaces for safety and health the individual level: encounters for other purposes, and counsel- protection, and expertise in risk management, i. Describe and develop a plan for im- ing patients about mitigating such risks. The including risk communication in an emer- plementing appropriate personal safety OEM clinician should consider opportunities gency. They establish emergency procedures for the responders. for addressing health risk reduction in a sys- and protocols for the clinical management ii. Design and implement a plan for ad- tematic fashion during clinical encounters for of individuals involved in disaster incidents, dressing the mental health needs of the periodic examinations, injury care, or other including specific medical management pro- responders. purposes. tocols. 3. Participate in the development of emergency or disaster plans for the workplace, OEM Clinical Specialist the community, or both: OEM Population Management The OEM clinical specialist should be i. Applying knowledge of occupational prepared to provide guidance to an organi- OEM physicians have long played a hazards, the workplace, and commu- zation about optimal health and productivity critical and dual role in emergency prepared- nity resources, work with local medi- programs to consider for the workforce and ness and response as both clinicians and pub- cal and community resources in devel- participate in decisions about contracting for lic health care officers for employed popula- oping an appropriate disaster response wellness services versus building these ser- tions. OEM physicians can add value to the plan. vices internally. The OEM clinical special- management of catastrophic consequences ii. Develop emergency response plans ist should be familiar with the research lit- in many ways, including but not limited to: ranging from developing patient treat- erature on cost/benefit, as well as resources workforce survival, continuity of business, ment protocols for a specific chemi- that can help an organization measure its connectivity to site and community-based cal to evacuation and community plan- risk and select appropriate components. The resources for assistance in a health-related ning for catastrophic industrial emer- physician should be able to assess the sci- emergency, surveillance of the workforce and gencies. entific evidence that supports the health risk the early detection of an outbreak, surge ca- 4. Establish emergency procedures and pro- assessment that is administered and any in- pacity in the event of a local event requir- tocols for the clinical management of tervention programs. Programs to consider ing mobilization of all available medical re- individuals involved in disaster incidents, include smoking cessation, physical activ- sources, population vaccination and chemo- including specific medical management ity, depression screening and management, prophylaxis programs and other protective protocols. nutritional/eating habits, blood pressure measures, assessing fitness of individuals to 5. Design and implement a plan for the miti- management, musculoskeletal care, and stay at or return to work, and determining gation of a disaster incident at the worksite weight management. OEM clinical special- when it is safe to reenter a contaminated site. or general community. ists should be prepared to support the or- The population management skills include 6. Assist in the design and implementation of ganization in creating a culture of behavior maintaining a thorough understanding of the a medical recovery plan for mass casualty change, while ensuring the selected program National Response Plan and Incident Com- events in industry or general community. aligns with the company’s business strategy mand Structure and remaining up to date with 7. Design and/or conduct an outbreak and/or and financial goals. The physician should be advances in emergency preparedness. (See cluster investigation. familiar with coaching philosophy, methods ACOEM position statement on the Role of 8. Design a pandemic preparedness plan for for engagement and sustaining employee par- Occupational and Environmental Medicine an organization. ticipation, and management of data, includ- Physicians in Emergency Preparedness and 9. Maintain a thorough understanding of lo- ing confidentiality and retention. The physi- 36) Response. cal, regional, state, and national response cian should be part of the team that se- plans and the incident command structure. lects the wellness partner and have an active Core Knowledge and Skills role in implementation. (See ACOEM posi- 1. Knowledge of local threats, for example, Health and Productivity tion statement on Depression in the Working nuclear plants, chemical production facil- The OEM physician should be able to Population.37) ities. identify and address individual and organi- 2. Participate in local emergency response zational factors in the workplace to optimize OEM Population Management exercises. the health of the worker and enhance pro- The OEM physician in a population 3. Understand how to activate/notify others ductivity. These issues most often include management role is expected to participate in the emergency response system. absenteeism, presenteeism, health enhance- in measuring risk related to chronic disease e34 C 2014 American College of Occupational and Environmental Medicine

and unhealthy behaviors, and the benefits of and practices, on the health and safety of ical specialist should be able to determine health and productivity programs. This in- workers. the cost-effectiveness and appropriateness of cludes assessing aggregate data from health various tests and also possess adequate skills risk assessments, health insurance claim data, Public Health, Surveillance, and in occupational and environmental health, in- and changes in measurements over time af- Disease Prevention cluding the ability to assess and respond to ter implementation of wellness-related pro- The OEM physician should have the individual and population risks for common grams. The physician should be able to un- knowledge and skill to develop, evaluate, and occupational and environmental disorders. derstand the reporting of data and the out- manage medical surveillance programs for These physicians should be familiar with risk comes that determine a return on investment. the workplace, as well as the general pub- communication principles and use these to The physician should be able to communicate lic. The physician should have the knowl- communicate information related to risk to this data to senior management of an orga- edge and skills to apply primary, secondary, workers, companies, and the public. OEM nization. In addition to measuring improve- and tertiary preventive methods. (ACGME clinical specialists who provide MRO ser- ment of health risks, the physician should be core competencies addressed: Patient Care, vices seek training, certification, and ongoing able to measure other outcomes such as im- Medical Knowledge, Practice-Based Learn- education in this area to appropriately evalu- provement on absenteeism and presenteeism ing and Improvement, Interpersonal and ate positive drug test results, make clinically within an organization, with the goal of a Communication Skills, Professionalism, and and administratively appropriate decisions, healthy, high-performance workforce. Systems-Based Practice.) and maintain awareness of schemes used by people to sabotage such testing. Conscien- Core Knowledge and Skills Clinical OEM Care Focus tious performance of the MRO role is criti- 1. Perform health risk assessments, biomet- Physicians providing OEM clinical cal for the protection of public safety when ric screenings, or other appropriate inter- care should be conversant with the screen- such testing is performed in workers with ventions to modify health risk behaviors ing guidelines and immunization and chemo- safety sensitive positions, including commer- in the clinical setting. prophylaxis recommendations for workers at cial driving. (See ACOEM position statement 2. Counsel employees about health risks and various stages of adulthood. This includes the on Medical Fitness to Drive in the Trans- lifestyle. US Preventive Services Task Force guide- portation Industry and the Impact on Public 39 3. Use tools and best practices for identify- lines for adult preventive medicine screen- Safety: Recommended Actions. ) ing, measuring, and modifying individual ing and guidelines created by the CDC and population health risk behaviors. related to blood-borne-pathogen exposure OEM Population Management 4. Accommodate cultural, ethnic, educa- evaluation and chemoprophylaxis and rec- The OEM physician focused on pop- tional, and language variations among ommended adult immunizations. Clinical ulation management should be prepared to workers when providing information on OEM physicians are expected to be conver- guide policies to ensure that workplace health occupational hazard prevention, disease sant with OSHA medical surveillance guide- surveillance programs are developed and im- prevention, and health promotion. lines and prepared to implement medical plemented. Physicians in this role analyze surveillance programs, including interpret- injury and illness data to identify trends Additional Knowledge and Skills ing data to identify and correct lapses in pri- and sentinel events. These physicians should Board-certified occupational medi- mary prevention, and take steps to prevent know how to perform a cluster analysis if in- cine specialists, physicians practicing as adverse health effects in patients exhibiting dicated or be able to garner the resources to OEM clinical specialists, and OEM popu- evidence of exposure. Clinical OEM physi- do such. The OEM physician involved in pop- lation managers should have the following cians also oversee the collection of specimens ulation management should be able to rec- additional knowledge and skills: related to substance abuse, including breath ognize outbreak events of public health sig- alcohol and urine drug tests; such collec- nificance and oversee programs for screen- 1. Design, implement, and evaluate worksite tion should follow strict rules, including em- ing to detect substance abuse and other po- health promotion and disease prevention ployee training, equipment calibration test- tential behavioral problems affecting worker programs, incorporating Department of ing, and chain of custody documentation. performance. OEM physicians in this role of- Health and Human Services and other au- ten participate in relevant research or work thoritative guidelines as appropriate (see OEM Clinical Specialist for nonprofit, academic, military, or govern- Workplace Health Protection and Promo- The OEM clinical specialist should be ment agencies dedicated to promoting public tion: A New Pathway for a Healthier—and familiar with the recommendations of gov- health and preventing disease. Safer—Workforce.38) Understand and ap- ernment advisory groups (eg, US Preven- ply the concepts of the National Institute tive Services Task Force, CDC, and hospi- Core Knowledge and Skills for Occupational Safety and Health Total tal infection control advisory committee on 1. Implement medical surveillance programs Worker HealthTM approach (available at immunizations) and incorporate their rec- in the workplace to protect workers, en- www.cdc.gov/niosh/twh/). ommendations in the design of appropriate suring compliance with applicable regu- 2. Describe the appropriate use and limita- immunization and screening programs for lations when appropriate. tions of health risk assessment and screen- the workplace. The OEM clinical special- i. Address specific work classifications, ing for healthy populations and the ap- ist should have a basic understanding of the such as hazardous waste workers. plications of screening, assessment, and statistical concepts of sensitivity, specificity, ii. Target specific organ systems for pre- early intervention for targeted high-risk positive predictive value, and negative prevention of occupational disease, such groups. dictive value. The OEM specialist should be as lung diseases. 3. Communicate current medical, environ- prepared to apply primary, secondary, and 2. Evaluate and manage situations of sus- mental, and/or other scientific knowledge tertiary preventive approaches to individual- pected chemical impairment, including effectively to target groups, including and population-based disease prevention and collection of specimens ensuring appro- patients, employees, employers, unions, health promotion, and be able to develop, im- priate chain of custody, in compliance community groups, and the media. plement, and evaluate the effectiveness of ap- with applicable rules and regulations. 4. Recognize the effects of cultural, ethnic, propriate clinical preventive services for both 3. Manage incidents of potential blood- and social factors, including health beliefs individuals and populations. The OEM clin- borne pathogen, tuberculosis, or other

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occupational infectious disease expo- 6. Apply primary, secondary, and tertiary ministrators, industrial hygienists, safety pro- sure according to applicable government prevention approaches to disease preven- fessionals, physical therapists, employers, le- guidelines. tion and health promotion to individuals gal experts, human resources professionals, 4. Intervene in response to positive findings and communities: insurance carriers, etc. The clinical OEM when indicated, to measurably improve i. Characterize the population to identify physician is a key member of this team and health outcomes. Also, interpret abnor- target conditions or exposures. may play an important leadership role in this mal laboratory findings in asymptomatic ii. Prioritize areas for prevention and mit- position. workers and recommend further evalua- igation. tion, treatment, or both as indicated. iii. Identify efficient and effective inter- OEM Clinical Specialist 5. Recognize and report or investigate poten- ventions. The OEM clinical specialist will be tial sentinel events. iv. Develop a strategy or plan for inter- called on not only for their expertise re- vention. garding OEM topics but also for their Additional Knowledge and Skills v. Implement the interventions. management and administrative knowledge Board-certified occupational medi- vi. Evaluate the effectiveness of pre- related to the field of OEM. OEM clin- cine specialists, physicians practicing as scribed interventions. ical specialists often serve as consultants OEM clinical specialists, and OEM popu- 7. Recommend and implement policies and in OEM employee health program devel- lation managers should have the following control measures to address emerging in- opment and management for companies, additional knowledge and skills: fectious diseases of concern. with responsibility for advising on a wide range of issues, for example, staffing, cre- 1. Develop, implement, evaluate, and refine OEM-Related Management and dentials, examination requirements, health screening programs for groups to iden- Administration records management, and wellness program tify risks for disease or injury and op- The OEM physician should have the features. Communicating and sharing such portunities to promote wellness and mit- administrative and management knowledge expertise might occur through presentations, igate progression in disease management and skills to plan, design, implement, man- talks, and other information sharing venues programs: age, and evaluate comprehensive occupa- involving interaction with many different i. Characterize the population to identify tional and environmental health programs audiences/stakeholders, including employ- target exposures, risk factors, and/or and projects. OEM physicians need an un- ees, employers, unions, administrators, pub- conditions of concern. derstanding of health care benefits, work- lic interest groups, communities, and poli- ii. Assess the utility of screening tools. ers’ compensation systems, electronic health cymakers. In all communications, the OEM iii. Identify outcome metrics of interest records and knowledge of the laws and reg- physician will honestly acknowledge uncer- to assess screening and intervention ulations applicable to the jurisdiction, indus- tainties and will always strive to convey the programs in a standardized fashion. try, and population of interest. OEM physi- truth as he or she knows and understands it. iv. Assess resources and measure return cians in all practice settings are expected An OEM clinical specialist may have a lead- on investment. to be sensitive to the diverse needs and ership role and/or assume the role of consul- v. Create structures (clinic staffing, etc). cultural backgrounds of those they serve, tant in multiple settings, including case man- vi. Report results. and anticipate meeting diverse needs in set- agement, administering/developing surveil- 2. Design and implement proactive systems ting up their practices. (ACGME core com- lance programs, evaluating sentinel events or of care that effectively reach all members petencies addressed: Practice-Based Learn- cluster outbreaks, protocol development, and of a population, including those at high ing and Improvement, Interpersonal and in policy development. risk and those who do not normally seek Communication Skills, Professionalism, and care. Systems-Based Practice.) (See ACOEM po- OEM Population Management 3. Design and conduct surveillance pro- sition statement on the Scope of Occupa- OEM physicians play an integral role grams in workplace, community settings, tional and Environmental Health Programs in many corporate, academic, and govern- or both: and Practice.40) ment settings. In such settings, to be op- i. Develop and implement medical timally effective, the OEM physician will surveillance programs in the work- Clinical OEM Care Focus have a large, comprehensive, and well- place and/or in communities exposed The clinical OEM physician is ex- balanced skill set. Such skills will typically to environmental contamination. pected to evaluate and implement clini- include management skills related to uti- ii. Understand basic epidemiological cal practice guidelines, quality improvement lization review and quality control/quality principles such as sensitivity, speci- programs, outcome assessment strategies, improvement activities, maximizing use of ficity, positive predictive value, and and medical informatics programs as they ap- information systems for appropriate track- negative predictive value. ply to day-to-day clinical patient care. Com- ing and benchmarking, and designing and iii. Utilize biomarkers to identify expo- petencies for the clinical OEM physician implementing appropriate projects and pro- sure, within limitations of the method- include selection and implementation of an tocols tailored to the needs of a specific ology, and interpret results in both appropriate electronic health record compli- group, audience, or population. OEM physi- clinical and public health contexts. ant with the applicable privacy standards, as cians play an increasingly critical role in iv. Evaluate the effectiveness of surveil- well as setting up an ethical and efficient cod- the management of population health and lance and screening programs. ing and billing system. The physician may be should develop and improve the skills needed 4. Review, interpret, and explain the public called on to assist with health program ed- to integrate data and trends, design ap- health and clinical implications of epi- ucation, marketing and promotion activities, propriate programs to manage and limit demiological studies that address occupa- and identifying potential customers/patients. disability, promote safe return to work, ap- tional hazards. It is also an essential skill for a clinical propriately and beneficially modify absen- 5. Apply validated epidemiological and bio- OEM physician to work well as a member teeism/presenteeism, and assist/educate oth- statistical principles and techniques to an- of a larger OEM team. Others on the “team” ers in developing and administering health alyze injury/illness data in defined worker may include physician colleagues, mid-level promotion/disease prevention programs that and community populations. practitioners, occupational health nurses, ad- fit into an evolving health care system. (See e36 C 2014 American College of Occupational and Environmental Medicine

ACOEM guidance and position statements lation managers should have the following Policy, Procedures, and Public Positions, and on Optimizing Health Care Delivery by additional knowledge and skills: approved by the ACOEM Board of Directors Integrating Workplaces, Homes, and Com- on January 25, 2014. This statement super- munities: How Occupational and Environ- 1. Design, implement, and evaluate clini- sedes the 2008 document. mental Medicine Can Serve as a Vital Con- cal practice guidelines, quality manage- necting Link Between Accountable Care ment/quality improvement programs, uti- Organizations and the Patient-Centered lization management, case management, REFERENCES 19 and other activities to enhance an organi- Medical Home ; Healthy Workforce/Healthy 1. American College of Occupational and En- Economy: The Role of Health, Productivity, zation’s performance. vironmental Medicine. American College of and Disability Management in Addressing 2. 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14. Ducatman AM, Vanderploeg JM, Johnson 23. Mueller K, Woo W, Cloeren M, Hegmann K, to High-Value Physician Services in M, et al. Residency training in preventive Martin D; ACOEM Task Force on the Use Workers’ Compensation. Elk Grove, IL: medicine: challenges and opportunities. Am J of Opioids. Principles for Ensuring the Safe American College of Occupational and Prev Med. 2005;28:403–412. Management of Pain Medication Prescriptions Environmental Medicine; 2010. Available at 15. Harber P, Wu S, Bontemps J, Rose S, Saechao by Occupational and Environmental Medicine http://www.acoem.org/uploadedFiles/Public K, Liu Y. Value of occupational medicine Physicians. Elk Grove, IL: American College Affairs/Policies And Position Statements/ board certification. J Occup Environ Med. of Occupational and Environmental Medicine; Guidelines/Library and Reference Material/ 2013;55:532–538. 2012. Available at http://www.acoem.org/ A%20Guide%20to%20High%20Value% 16. 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r PublicSafety.aspx. Accessed February 24, 13, 2007. All residency programs must inte- Communicate effectively with patients, 2014. grate these competencies into the curriculum: families, and the public, as appropriate, 40. Corporate Health Achievement Award r across a broad range of socioeconomic and Patient Care Committee. ACOEM Position Statement. r cultural backgrounds. Medical Knowledge r Scope of Occupational and Environmen- r Communicate effectively with physicians, Practice-Based Learning and Improve- tal Health Programs and Practice.Elk other health care professionals, and health- Grove, IL: American College of Occu- ment r related agencies. pational and Environmental Medicine; Interpersonal Skills and Communication r r Work effectively as a member or leader of 2011. Available at http://www.acoem. Professionalism r a health care team or other professional org/Scope HealthPrograms Practice.aspx. Systems-Based Practice Accessed February 24, 2014. r group. 41. Special Committee on Health, Productivity, Act in a consultative role to other physi- and Disability Management. ACOEM Posi- Patient Care r cians and health care professionals. tion Statement. Healthy workforce/healthy Residents must be able to provide pa- Maintain comprehensive, timely, and legi- economy: the role of health, productivity, tient care that is compassionate, appropriate, ble medical records, if applicable. and disability management in addressing and effective for the treatment of health prob- the nation’s health care crisis: why an em- Professionalism phasis on the health of the workforce is lems and the promotion of health. vital to the health of the economy. J Occup Residents must demonstrate a com- Environ Med. 2009;51:114–119. Available Medical Knowledge mitment to carrying out professional respon- at http://journals.lww.com/joem/Fulltext/ Residents must demonstrate knowl- sibilities and an adherence to ethical princi- 2009/01000/Healthy Workforce Healthy edge of established and evolving biomed- ples. Residents are expected to demonstrate Economy The Role of.16.aspx. Accessed ical, clinical, epidemiological, and social- the following: February 24, 2014. behavioral sciences, as well as the application r 42. Cummings C; ACOEM Emergency Pre- Compassion, integrity, and respect for of this knowledge to patient care. Residents others. paredness Task Force. Pandemic influenza are expected to: r guidance for corporations. J Occup Env- Responsiveness to patient needs that su- iron Med. 2011;53:690–694. Available at persedes self-interest. http://journals.lww.com/joem/Fulltext/2011/ Practice-Based Learning r r Respect for patient privacy and autonomy. 06000/Pandemic Influenza Guidance for and Improvement Accountability to patients, society, and the Corporations.16.aspx. Accessed February 24, Residents must demonstrate the ability r profession. 2014. to investigate and evaluate their care of pa- Sensitivity and responsiveness to a diverse 43. Joint Consensus Statement of the Health En- tients, to appraise and assimilate scientific ev- patient population, including but not lim- hancement Research Organization; American idence, and to continuously improve patient College of Occupational and Environmental ited to diversity in gender, age, culture, care on the basis of constant self-evaluation race, religion, disabilities, and sexual ori- Medicine (ACOEM); American Cancer and lifelong learning. Residents are expected Society (ACS) and American Cancer Society entation. Cancer Action Network; American Diabetes to develop skills and habits to be able to meet Association (ADA); American Heart Asso- the following goals: Systems-Based Practice r ciation (AHA). Guidance for a reasonably Identify strengths, deficiencies, and limits Residents must demonstrate an aware- designed, employer-sponsored wellness in one’s knowledge and expertise ness of and responsiveness to the larger con- program using outcomes-based incentives. J r text and system of health care, as well as the Occup Environ Med. 2012;54:889–896. Avail- r Set learning and improvement goals able at http://journals.lww.com/joem/Fulltext/ Identify and perform appropriate learning ability to call effectively on other resources in the system to provide optimal health care. 2012/07000/Guidance for a Reasonably r activities Designed,.20.aspx. Accessed February 24, Systematically analyze practice, using Residents are expected to do the following: r 2014. quality improvement methods, and imple- Work effectively in various health care de- ment changes with the goal of practice im- livery settings and systems relevant to their APPENDIX 1 provement r r clinical specialty. Incorporate formative evaluation feedback Coordinate patient care within the health ACGME Six Competencies r into daily practice care system relevant to their clinical spe- The Accreditation Council for Gradu- Locate, appraise, and assimilate evidence r cialty. ate Medical Education (ACGME) is a private, from scientific studies related to their pa- Incorporate considerations of cost aware- nonprofit council that evaluates and accred- r tients’ health problems ness and risk–benefit analysis in patient its medical residency programs in the United Use information technology to optimize and/or population-based care as appropri- States. The ACGME was established in 1981 learning r r ate. and its mission is to improve health care by Participate in the education of patients, Advocate for quality patient care and op- assessing and advancing the quality of res- families, students, residents, and other r timal patient care systems. ident physicians’ education through exem- health care professionals Work in interprofessional teams to en- plary accreditation. In academic year 2008– hance patient safety and improve patient 2009, there were 8734 ACGME-accredited Interpersonal and Communication r care quality. residency programs in 130 specialties and Skills Participate in identifying system errors subspecialties. The number of active full- Residents must demonstrate interper- and implementing potential systems solu- and part-time residents for academic year sonal and communication skills that result tions. 2008–2009 was 109,482. The ACGME rec- in the effective exchange of information and ommended all residency programs to evalu- collaboration with patients, their families, Additional information about ate their trainees under six core competencies and other health care professionals. Residents ACGME is available on line at http://www approved by the ACGME Board on February are expected to do the following: .acgme.org/acWebsite/home/home.asp.

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APPENDIX 2 The Preventive Medicine Milestone v. Identify and secure necessary re- Project is available on line at www.acgme sources. The Preventive Medicine .org/acgmeweb/Portals/0/PDFs/Milestones/ vi. Collect and prepare data for analysis. Milestone Project: Occupational PreventiveMedicineMilestones-Occupational vii. Analyze data and present results Medicine Link Medicine.pdf. in tabular, graphical, and verbal The Preventive Medicine Milestone formats. Project: Occupational Medicine is a joint ini- APPENDIX 3 viii. Draw conclusions and discuss the im- tiative of the Accreditation Council for Grad- plications limitations of the research uate Medical Education and the American OEM Research and Education ﬁndings. Board of Preventive Medicine published in The profession of medicine requires 2. Write a report suitable for publication. August 2013. ongoing scholarly inquiry, lifelong learning, 3. Identify learning needs, design a curricu- and the ability to teach others. If an OEM lum, conduct a course, and evaluate learn- The milestones are designed only physician participates in research or edu- ing outcomes. for use in evaluation of resident cation, competence in the techniques and 4. Interpret and present technical and clinical physicians in the context of their methodologies of research and education is data for various audiences: participation in ACGME-accredited required. i. Apply principles of adult learning. residency or fellowship programs. ii. Handle oral presentations in a profes- 1. Design and conduct a scientiﬁc investiga- The milestones provide a framework sional manner. tion: for assessment of the development iii. Prepare effective written reports for i. Formulate a hypothesis. of the resident physician in key various audiences. ii. Perform a literature review. dimensions of the elements of physi- iv. Defend conclusions and recommenda- iii. Select and apply research design meth- cian competency in a specialty or tions, using appropriate data and logical ods, including knowledge of biostatis- subspecialty. They neither represent reasoning. tics and epidemiology when applicable. the entirety of the dimensions of the v. Evaluate learning outcomes. six domains of physician competency, iv. Seek and secure human or animal nor are they designed to be relevant subjects for panel approval when in any other context. indicated.

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