OCCUPATIONAL MEDICINE SYMPOSIA U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Center for Disease Control National Institute for Occupational Safety and Health Division of Occupational Health Programs ----- - . Rockville,. ·-- --r---�--Maryland May 1975 This publication contains major papers presented at the 34th American Medical Association Congress on Occupational Health, held September 9 to 10, 1974 in Chicago, Illinois. The Congress was supported in part by the National Institute for Occupational Safety and Health through Contract No. CDC-99-74-30. Dr. Henry Howe was AMA Project Director and compiled the initial proceedings from the verbatim transcript. The assistance of the following individuals is gratefully acknowledged: Ernest B. Howard, M.D. William R. Barclay, M.D. Asher J. Finkel, M.D. Henry F. Howe, M.D. CDC-NIOSH David J. Sencer, M.D. Marcus M. Key, M.D. Raymond T. ~oore, M.D. A. Walter Hoover, M.D. Leo A. Sanders Marilyn K. Hutchison, M.D. HEW Publication No. (NIOSH) 75-189 FOREWORD A primary goal of the National Institute for Occupational Safety and Health is to promote effective health care for American working men and women. Since the passage of the Occupational Safety and Health Act of 1970, a growing number of family practitioners and internists have entered the part-time practice of occupational medicine. Helping these physicians to incorporate the concepts and skills of occupational medical practice into the total delivery of health services is a major consideration of the Institute's Division of Occupational Health Programs. Toward this end, NIOSH co-sponsored the AMA's 34th Annual Congress on Occupational Health and cooperated in developing the scientific program for the Congress. The seven symposia of the Congress were presented by prominent and eminently qualified speakers from a variety of medical specialties, industrial hygiene, and engineering. The program was a unique and comprehensive review of selected areas of occupational medical practice. NIOSH is publishing the major papers presented at the Congress in this text in order to bring the benefits of this unusual program to as many individuals in the field as possible. if ~ I{) J John F. Finklea, M.D. Director, National Institute for Occupational Safety and Health PREFACE The enthusiastic response of participants to the program presented at the AMA 34th Annual Congress on Occupational Health, co-sponsored by the National Institute for Occupational Safety and Health, led to NIOSH's publication of these symposia. It is hoped that this reference text will stimulate the interest of physicians in the particular opportunities and problems of occupational medical practice, as well as meet the needs of the growing number of physicians who find occupational health considerations now a part of their practice. The manuscript was prepared from verbatim transcripts of the Congress proceedings. Papers are published essentially as presented. However, they were edited by NIOSH for written presentation and titles were assigned to facilitate the use of the publication. Also, an Editor's note has been inserted· to introduce the papers in Symposium II and to clarify references made by the speakers to NIOSH Programs. Except for NIOSH speakers, the papers do not necessarily represent the views of NIOSH but are presented as an introduction to the practice and controversies of occupational medicine. The Congress also included 1ive1y'and informative question and answer sessions. However, it was not possible to transcribe these sessions in this text due to their length and informality. The Division of Occupational Health Programs has a limited number of transcripts of this part of the Congress and will send individual copies on request while supplies last. Marilyn K. Hutchison, M.D. Acting Director, Division of Occupational Health Programs TABLE OF CONTENTS PAGE FOREWORD iii PREFACE v ABSTRACT vii INTRODUCTION vii OCCUPATIONAL PULMONARY DISEASES Hypersensitivity Pneumonitis, Howard A. Buechner, M.D. I-I Silicosis, Howard S. VanOrstrand, M.D. 1-8 VIEWBOX CHEST X-RAY DEMONSTRATION, OCCUPATIONAL PULMONARY DISEASES ly American College of Radiology Radiological Changes In Pneumoconiosis, Including Coal Workers' Pneumoconiosis, George Jacobson, H.D. ••••••• • •••• " ••••• II-4 Asbestosis, George Jacobson, M.D •••.••••••••••••••••• II-B A Plastic Step-Block For Testing Film Quality, E. Dale Trout, Sc.D•••• II-ll Good Film Quality For Detecting Pneumoconiosis, E. Nicholas ,Sargent, M.D. II-13 International Classification Of Pneumoconioses, Leonard J. Bristol, M.D. II-17 CARDIOVASCULAR DISEASE IN OCCUPATIONAL MEDICINE Diagnosis Of Coronary Heart Disease, Nicholas DePasquale, M.D. III-I Job Placement And Management Of The Cardiac Patient At Work, Leon J. Warshaw" M.D •••••••.••••.•••••••• 1II-7 Occupational Health Service, Seven Common Problems, E. R. Plunkett, M.D. III-12 Prevention Of Coronary Heart Disease, James A. Schoenberger, M.D •• III-17 CARDIOVASCULAR DEMONSTRATION WORK EVALUATION STRESS TESTING Graded Exercise Testing, I. Martin Grais, M.D. IV-I Exercise Testing In Preventive Medicine, Jean Spencer Felton, M.D. IV-6 Exercise Therapy For Angina, John E. Smith, M.D. IV-13 PAGE MEDICAL MONITORING FOR OCCUPATIONAL DISEASE A New Phase For Occupational Medicine, Irving R. Tabershaw, M.D •••••• V-l How Can Monitoring Be Accomplished? Rita Dingman, R.N., M.P.H. • ••• V-6 Administrative Problems Related To Medical Monitoring, Merle Bundy, M.D •• V-l1 Medical Monitoring And Two New Standards, Miles o. Colwell, M.D ••••• V-l4 MISSED AND MIS-DIAGNOSES IN CHEMICAL EXPOSURES Chemical Exposure, Three Case Histories, Carl U. Dernehl, M.D •• VI-3 Carbon Monoxide And Lead Exposure, Bertram D. Dinman, M.D. VI-6 Occupational Dermatoses, Donald J. Birmingham, M. D•••• VI-9 Noise, Hearing, And Audiometry, Richard A. Nelson, M.D. VI-l4 INDUSTRIAL HYGIENE DEMONSTRATION OF ENVIRONMENTAL MEASUREMENT TECHNIQUES Monitoring The Occupational Environment, General Concepts, Jerome T. Siedlecki, M.S ••••••••' ••••••• VII-l Measurement Of Particulates, Robert Weidner, M.S. VII-5 Measurement Of Gases And Vapors, Julian B. Olishifski, P.E. VII-9 Measurement Of Physical Agents, C. Lyle Cheever, M.D. VII-l2 APPENDIX--INDEX OF SPEAKERS AND MODERATORS • A-l OCCUPATIONAL MEDICINE SYMPOSIA ABSTRACT Through a survey of AMA-member physicians, NIOSH determined the primary occupational medicine problems and information needs of private practitioners with part-time occupational medicine responsibilities. The results of the survey were used to develop the program of the 1974 AMA Congress on Occupational Health, co-sponsored by NIOSH. Papers were presented on the following topics: Occupational pulmonary diseases; chest X-rays for the detection of pneumoconioses; cardiovascular disease in occupational medicine; work evaluation and stress testing; medical monitoring for occupational disease; chemical exposures; noise, hearing, and audiometry, and environmental measurement techniques. The papers presented at the meeting, published by NIOSH, are an introductory text, highlighting the aspects of occupational medicine most significant to part-time plant physicians, to private practitioners generally, and to others with related interests. INTRODUCTION The Occupational Safety and Health Act of 1970 directed the attention of many elements of Ameri­ can society, including the health professions, to the health and safety problems of Americans on the job. In its efforts to promote effective health care for American working men and women, the National Institute for Occupational Safety and Health (NIOSH) has developed programs to assist the assimilation of occupational medicine concepts and skills into general health care delivery. The exact number of physicians who work in occupational medicine is not known, but there are indications that the number of physicians with part-time industrial practice is increasing. Those who seek specialized information often find that appropriate educational opportunities are limited. Accordingly, NIOSH's Division of Occupational Health Programs surveyed 800 AHA member physicians to identify their specific interests in continuing education related to occupational medicine. The physicians surveyed were chosen on the basis of AMA professional records indicating at least some time spent in occupational medicine. Topics which were ranked highest by respondents included occupational pulmonary diseases, cardiovascular diseases, medical minotoring, and tox­ icology. This information has been added to the criteria used by NIOSH in evaluating the direction, impact, and content of occupational health programs. .Specifically, the interests revealed by the 800 part-time occupational health physicians surveyed have led to NIOSH programs designed to promote the exchange of pertinent and practical information for the health practitioner. In one such activity, NIOSH co-sponsored the AMA's 34th Congress on Occupational Health, September 9-10, 1974, Chicago, Illinois. This prestigious annual event is one of the few sources of continuing professional education in occupational medicine available to medical practitioners. The results of the survey were used in developing the scientific program for the Congress in order to include subjects of high priority for prospective attendees, in particular, those with limited occupational medicine training and/or part-time industrial practice. In addition, the Congress was designed as a workshop in order to allow optimum audience partici­ pation and