American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Objectives

– Understand the scope and practice of OM – Name 2 historical OM figures – Identify significant laws – Name one major preventive health initiative in which OM plays an important role – Enumerate OM services delivery methods Scott C. Jones, DO, MPH, FAOCOPM – Explain the essential and elective components of St. Petersburg, Florida an OM practice March 14, 2012

American Osteopathic College of Occupational and Preventive Medicine

Definition of Occupational Medicine Why Occ Med?

• The ONLY medical specialty trained in the • The branch of medicine that deals with the interaction between the worker and the work prevention and treatment of occupational injuries place! and diseases. • OccDocs MUST know the work environment of • An occupational disease is one that is associated their patients! with a particular occupation and occurs in the workplace. • Companies MUST know their OccDocs! • Some occupations confer specific risks, such as the prevalence of black lung in coal miners. Now for some Occ Med History…

History of Occupational Medicine Pliny the Elder 23 - 79 AD

• “The fumes from silver mines • Mirrors the history of medicine are harmful to all animals…” • “…when well shafts have • Hippocratic teaching (460-377 BC) about observation been sunk deep, fumes of and balance, not superstitious sulfur or alum rush up to – “Observe the patient’s condition and their response to meet the diggers and kill disease, rather than the disease itself.” them.” • Animal bladder “veils” to protect miners

A-1 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Galen 131 - 200 AD Rhazes c850 - 923

• Physician to the gladiators • Documented occupations of under Marcus Aurelius patients • Accomplished surgeon, wrote – Cotton merchant about procedures and – Cloth merchant instruments – Goldsmith – • Wound treatment in the work bookseller place • Observations of mine workers exposed to acid mists

Bernardino Ramazzini 1633 - 1714 “Disease of Scribes and Notaries”

• “To the questions • “An acquaintance of mine, a notary by recommended by Hippocrates, profession, still living, used to spend his whole he [physician] should ask one life continually engaged in writing, and he more – What is your made a good deal of money from it; first he occupation?” began to complain of intense fatigue in the • Pioneered field of Ergonomics whole arm, but no remedy could relieve this, … • Visited workers and workplaces

“Disease of Scribes… ” Recommended Reading

• “…and finally the whole right arm became • Lancet article: Lancet 19999;354:858-61 completely paralyzed. In order to offset this infirmity he began to train himself to write with the left hand, but it was not very long before it too was attacked by the same malady.”

A-2 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Percival Pott 1714 - 1788 Thomas Morrison Legge 1863 - 1932 • First medical inspector of • Scrotal cancers in chimney factories in England sweeps • Lead Poisoning and Lead • “pioneer of observational Absorption epidemiology” • Recommended banning indoor • “Father” of environmental lead paint carcinogenesis • Occ med in medical school curriculum

Alice Hamilton 1869 - 1970 Alice Hamilton Award

• pioneer of toxicology From CDC/NIOSH Website: • 1919 first woman appointed to faculty at Harvard Medical • Alice Hamilton Awards School, Department of Industrial The Alice Hamilton Awards for Occupational Safety and Health recognize the scientific excellence of technical and instructional materials by NIOSH Medicine scientists and engineers in the areas of biological science, engineering and • national expert on exposures to physical science, human studies, and educational materials. toxic chemicals in the workplace, • The Awards honor Dr. Alice Hamilton (1869 - 1970), a pioneering especially lead researcher and occupational physician, and are presented each year by NIOSH on the basis of rigorous reviews by panels of scientific experts from • active role in exposing the 1924 outside the Institute. Ethyl leaded gasoline and 1928 "radium girls" industrial disasters

http://www.cdc.gov/niosh/hamilton/defa ult.html

Scott C. Jones, DO, MPH 1959 - present

• Board Cert. Occ Med • DOCPCMS • Medical Director – BJC CHS – St. Louis Metro Police Dept – St. Louis County Police Dept – Metro Bistate • Compensation Systems – State WC – FELA – Jones/Longshoremans’

A-3 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Historical Events Historical Events

• Factory Act of 1867 • Worker Compensation Laws – Restricted hours during – No fault insurance coverage for injured workers which children, young – Early 1900’s workers and women – State based programs and laws were permitted to labor – Employee right-to-choose; right-to-know – Any contested cases are adjudicated by state compensation boards – Burden of proof on worker

Historical Events Historical Events

• Occupational Medicine became specialty 1954 • EPA established 1970 – • OSHA established 1970 – safe working environment – Regulates pesticides, • NIOSH established 1970 – research agency – Enforces Toxic Substance Control Act (TSCA) – Noise Control Act – And many more since then

Occupational Health Services Team Approach

• Physician • Safety Officers • • What does one do in occupational medicine? • Occupational Health Industrial Hygienist Nurse • Management (plant • What is the scope of services? • PAs and NPs manager, HR dept) • Ergonomic team • Physical Therapist • Environmental team • Quality Care: Clinical v. Occ Med • Case Manager • TPAs – Internal • Insurance Cos. – External

A-4 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Types of Services Clinical Services

• Clinical • Examinations • Ancillary – Pre-placement – Return to work • Preventive – Fitness for duty • Health Promotion Programs – Respirator clearance • Health and Productivity Management – Periodic Surveillance • Worker Health as force for National Health – Disability examinations Policy reform – IME • Injury Care

Ancillary Services Preventive Health Services

• Audiometric • Health Promotion Programs – Smoking cessation • Spirometry – Stress reduction • Visual testing – Nutritional counseling • Laboratory testing – Mental Health and Depression – Sedentary Lifestyle interventions • X-rays • Periodic evaluations • Physical Therapy – Risk assessment • MRO Drug Testing – Lifestyle factors – Appraisals of health (HRAs)

Healthy People 2020 Healthy People 2020

Access Health Services Family Planning Lesbian, Gay, Bisexual, and Transgender Preparedness New Adolescent Health New Food Safety Health New Public Health Infrastructure Arthritis, Osteoporosis, and Chronic Back Genomics New Maternal, Infant, and Child Health Respiratory Diseases Conditions Global Health New Medical Product Safety Sexually Transmitted Diseases Blood Disorders and Blood Safety New Health Communication and Health Mental Health and Mental Disorders Sleep Health New Cancer Information Technology Nutrition and Weight Status Social Determinants of Health New Chronic Kidney Disease Healthcare-Associated Infections New Occupational Safety and Health Substance Abuse Dementias, Including Alzheimer’s Disease Health-Related Quality of Life & Well- Older Adults New Tobacco Use New Being New Oral Health Vision Diabetes Hearing and Other Sensory or Physical Health Disability and Health Communication Disorders Early and Middle Childhood New Heart Disease and Stroke Educational and Community-Based HIV Programs Immunization and Infectious Diseases Environmental Health Injury and Violence Prevention Topics marked "New" are topic areas that were not included in Healthy People 2010. * http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx

A-5 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Types of Occ Med Practices Basic Function of Occ Physician

• Multi-specialty group practices • Provide high-quality medical services • Corporate-based clinics – i.e. give good EBM care • Private practice • Understand company’s objectives • Hospital based programs – Medical conscience for employers • University/ Teaching/ Residency • Aid in regulatory compliance – • Primary care offices OSHA, EPA, DOT • Marketing and billing

Work-Site Visit Work-Site Visit

• First impressions count • Observe workers working • Number of employees • Observe workers arriving, on breaks and leaving • Number of shifts • Physical environment: temp., odor, vibration, noise • Union or non-union shop • General safety – machine guards, safety showers, • Health/medical services available signs, trip hazards • Essential Functions in Job Descriptions • Eating area, wash room • Review the Material Safety Data Sheet – MSDS • Ergonomic issues – heavy lifting, repetitive motion, • General housekeeping (spills, cleanliness) awkward positions

Work-Site Visit Assisting Employer

• Chemical, physical, biological hazards • OSHA compliance • Dermal exposures – Respiratory Protection Program • Respiratory exposures – Hearing conservation programs • Use of PPE – DOT requirements • Ventilation/ exhaust systems, administrative controls

A-6 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Evidence Based Medicine Approach to Occ Injury & Illness

"the conscientious, explicit and judicious use of • Subjective information current best evidence in making decisions – History of present illness or injury about the care of the individual patient. It • In patient’s own words…”xyz” means integrating individual clinical expertise – Job history: past and present with the best available external clinical – Exposure history: work, hobbies, environmental evidence from systematic research." (e.g. Doe Run) Dr. David Sackett, 1996 – ROS for temporal relationships – History of Present Injury/Illness

Approach to Occ Injury & Illness Work Relatedness

• Objective • “Definitive causation assessments should be – Physical examination, functional testing based on considerably more information than – Lab and x-ray – Work place visit preliminary assessments.” • Assessment – diagnoses, opinion on WR • Objective vs. Subjective • Plan – “straight shooter” – Medication: OTC v. Rx – “nice person” – Restrictions: based on injury NOT work – – HEP, Physical Therapy, exercise prescription Did YOU witness the incident? – Care plan, manage expectations, recheck

Case Management Timeline

DOI ARTW RTW Closure

Injury Disability Management Management

OMP (Out of Medical Process)

A-7 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Injury Management Disability Management Review Records for Abilities Doctors On-Call Second Opinion Exam Functional Testing On Call Physician Vocational Counseling Managers, Co-workers, Communication of Expectations Observe Safety & Productivity

DOI ARTW ARTW RTW Closure

Interventions more effective Interventions less effective

Ideally, ARTW=RTW date

OMP

Tools of Evidence Based Medicine

• MOI Investigation • ICD-9 (ICD 10) • ACOEM Occupational Medicine Treatment Guidelines • Official Disability Guidelines • Medical Disability Advisor • AMA Guides to the Evaluation of Permanent Impairment

ACOEM Occupational Medicine Treatment Guidelines I. Foundations of Occupational Medicine Practice 1. Prevention 2. General Approach to Initial Assessment 3. Initial Approaches to Treatment 4. Work Relatedness 5. Cornerstones of Disability Management 6. Case Management: Prevention and Management of Delayed Functional Recovery 7. Pain Behavior, Inconsistent Findings and Motivation for Self-Care and Recovery 8. Consultations and Independent Medical Examinations 9. Reintegration and Reconditioning after Testing or Surgery

A-8 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Prevention Strategies Delayed Recovery

• Primary – avoid incident • Exam findings – Safe work place – Fit worker • Functional data in chart • Secondary – avoid disability – Rehab – Proper Treatment • Disability duration guides – BIC • • Tertiary – avoid recurrence FCE – FFD • Natural history of condition – Fit work to worker • surveillance Involve your Occ Doc!

ACOEM Occupational Medicine Treatment Guidelines II. Presenting Complaints 10. Neck and Upper Back 11. Shoulder 12. Elbow 13. Forearm, Wrist and Hand 14. Low Back 15. Knee 16. Ankle and Foot 17. Acute Eye Complaints 18. Stress-Related

Practical Application ODG: Official Disability Guidelines

ICD 9Diagnosis • RTW data and Best Practices • Causality Likelihood 724.5 Backache • Medical Costs 726.1 Rotator Cuff Syndrome Shoulder • Case Management Triage 845.0 Ankle Sprain or Strain – Levels I, II, III and inflection point • Physical Therapy Guidelines • DD Adjustment Factors by Age

A-9 American Osteopathic College of Occupational and Preventive Medicine Basic Course in Occupational and Environmental Medicine, Part I March 14, 2012, St. Petersburg, Florida

Strategies for a successful Workers’ Compensation Program

Commitment 1.Gain support of administration for consistent P from 1.Consistent enforcement of P&P enforcement of P&P R leadership and 2.Participation in routine meetings to review 2.Meet with key stakeholders at least once a year health and discuss issues. to report on compliance. E providers V Effective 1.Understand how P&P are developed and policies and 1.Clear processes for work related injuries, approved in the organization. E procedures illnesses and exposures 2.Work with HR, Legal, Finance to create P&P that N 2.Policies address key components supports goals. 3.Ongoing communication of P&P 3.Develop and deliver material at new employee T orientation, ongoing supervisor training. I Ongoing 1.Frequency and severity compared to past and analysis of 1.Monthly and annual comparisons against similar organizations O data past experiences & industry data 2.Interdisciplinary effort to identify and address N 2.In depth analysis of problem areas high risk issues unique to the organization Interventions 1.Identify responsible party for the program targeted at 1.Use data and risk assessment to create 2.There will be a positive ROI for funding targeted high risk targeted initiatives interventions issues 2.Implementation of intervention plan (e.g. ergonomics) Access to 1.Create direct communication line with medical C timely 1.Employer communicates key information to providers. O evidenced medical provider. 2.Insist that medical providers practice evidence based care 2.Data is generated, communicated and based medicine. N incorporated into plan of care. T Disciplined 1.Evaluation by OM specialist with attention to oversight of 1.Management begins at the point of work status, medications and follow up. R medical discovery. 2.Use of pain charts, Official Disability Guidelines process 2.Consistent application of Evidence Based (ODG), etc O Medicine. 3. Develop expertise in use of ODG. L Ongoing education for claims adjustors and 4.Share expertise with key players. case managers.

A-10