The Physician's Role in Occupational Health: Patient Care and Prevention

University of Maryland - School of Medicine
Baltimore, Maryland

Instructor(s): Keogh, James P.; Gordon, Janie
Subject area: Health / Medicine
Department: Occupational and Environmental Health
Level: Undergraduate
Duration of exercise: 2 hours
Learning objective: Develop Individual Skills, Provide Real-World Experience
Teaching style: Active Learning, Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.


This is an Instructor's guide for an exercise with undergraduate medical students at the University of Maryland Medical School. Students will learn to:

8:00 AM to 9:50 AM
Taking care of patients with occupational illnesses and injuries: How physicians in practice help prevent occupational injury and illness

Methods:
1. Review of information gathered in the first session
2. Use of a patient video to stimulate discussion of the physician's role
3. Small group discussion of steps in caring for and following up a patient with an occupational or environmental disease
4. Small group discussion of the roles of patient, employer, union, and government agency in investigation and prevention
5. Preparation for the worksite visit

Once everyone is assembled and settling down, any new instructors (some groups will have a new resource person or primary instructor) should introduce themselves. You may then want to introduce the two general objectives for this morning's two hour small group:
8:00 to 8:30
Discussion and synthesis of material from session 1
The first 20 minutes or so of today's session can be used to discuss and synthesize what the group has learned about their "patient" from session 1 and then about the entire process. During this session the resource group leaders can be used as resources for information, but the primary group leader should still guide discussion in such a way as to prevent "lecturing" and stimulate questioning and discussion.

During this review of the group members' fact finding missions, the primary group leader should ask questions not only about the specific case, but also about the students' general impressions of the accessibility and usefulness of the resources they used. The instructors can cautiously join in this process, but the focus should be on eliciting information from the learners, and on their identifying gaps in knowledge, not on providing facts. It's likely that most of the group heard about most of the available information about your "patient." At the same time each of the students probably learned some unique things about occupational and environmental health topics from the last session. Drawing each of them into the discussion will enrich everyone's experience. There will be some fact sheets that circulated during the information gathering session that not everyone will have read about various topics. (These are in the Additional Materials section of the Instructor Manual. You will also get some hard-copies when you check-in in the morning, for any students who may want them. ) Ask what the students know about the pathophysiology of the "patient's" problem. The primary instructor can guide a brief clinical discussion if this seems profitable, but resist the temptation to lecture.

What is the role of ______ (employer union, poison center, MOSH, MDE) and how does that differ from _________ (Please contrast different groups/agencies to one another.)
What are the strengths and limitations of each of these roles in assuring a safe workplace?
Ask about the pros and cons of various approaches to fact finding:
Is that the way you would go about it, ...... (student's name)?
If a hazardous situation is found, what can be done to get it corrected?

It's likely the students will be seeing a connection between this patient's home or work environment and the cause or the course of their illness. Ask them what they would tell the patient about this. Step back to ask the more general question "How do you know if an illness is work related or related to some specific exposure in the home or community environment?" Encourage the group to abstract some of the general concepts used in determining work relatedness. They are likely to come up with a number including:We will be revisiting the issue of how much or how little we know about hazards later in the last small group session.

We'll be showing our patient video to help stimulate the next session

8:30 to 9:00
"The doctor never asked me." Video.
Up until now our focus has been primarily on the case the group worked to diagnose in the last session. Now we shift our focus to what happens after diagnosis. If students haven't already moved past diagnosis to care and follow up, challenge your group with the following question: Now that you have a good idea of the diagnosis, what do you as the physician need to do to take care of this patient ?

In most cases, arriving at the correct diagnosis is only the beginning of the process. Depending on the case your students worked on in the last session, they may see that this patient would need medical treatment, rehabilitative services, some change in the job assignment, and financial support while off work. Not every case raises the same issues, and you will need to draw the students out to cover those areas that don't flow naturally from the discussion of this case. It's likely that the students will spontaneously raise issues of worker's compensation, income replacement, rehabilitation, investigation and prevention of future illnesses and injuries, etc. Keep the discussion broad and general at first.

Let the students kick this around for a very brief time and then interrupt to say that: "One way to get at this question is to ask our patients what they need and what they expect of us. Since we couldn't arrange to bring in patients to talk to each of the small groups today we will use a video tape of patients talking about their illnesses."

8:40: Show "The doctor never asked me." Video (it runs 15 minutes). You will have a brief study guide to hand out, and you should mention that these are all real patients seen here at University. The video will be "shown" simultaneously from a central audio visual room to all groups, on the mounted monitor in each small group room. There will be an announcement both 5 minutes and immediately prior to the video starting. (This change saves lots of fetching and returning of VCRs.)

If students have questions about the video:
The patients had all been referred to the Occupational Medicine Clinic at UM. They were interviewed by Susan Hadary Cohen of UM Video Press. She had never met the patients before these interviews, nor were the patients rehearsed ahead of time. After a brief warm up chat she got them to talk to her on camera about their illnesses. The tape has subsequently been edited to select those parts of the interviews in which the patients discuss their experiences with physicians and the consequences of the physician's recognition of their illnesses. The fact that three of the four had lead poisoning and one had carpal tunnel is merely the coincidence of who was available on the days we taped. The tape is being used in a number of medical schools and residencies around the country.

9:00 to 9:20 am
Caring for the patient with an occupational injury or illness

Please give the students a chance to voice their immediate reactions to the video and the issues raised by it. Then give the students a 5-10 minute break before continuing a more in-depth discussion.

The instructors should stimulate and if necessary guide the discussion that the video stimulates into two broad areas: What do we need to do for this patient? for the first 20 minutes or so and then What do we need to do to prevent others from being injured or becoming ill? during the rest of the session. We have listed specific questions relating to patient care ( compensation, rehabilitation, etc.) first and then those related to disease prevention. In many situations the two issues are closely intertwined, and your group may range back and forth. Use questions to redirect them if you feel important issues are being neglected. We think that the students will have collectively picked up a good deal of knowledge from their discussions during the round robin session in the last session, along with a variety of fact sheets and pointers about relevant sections of the text. Both instructors can add information as needed to answer questions and to round out the discussion, but do so sparingly. Even misinformation is best dealt with by waiting and letting a classmate correct it, whenever possible

As before, we want to move back and forth from the specifics of the patient from session one and/or the patients in the video to the more general. Keep the "ball of string" moving back and forth between students by asking a question, and then addressing one of them to answer it. (see Hints for Small group discussion.) One of the students or one of the instructors can list on the blackboard or a large piece of paper a "to do list" of things the physician may need to deal with.

We hope the students will discuss the worker's compensation system and its strengths and weaknesses, the availability of other sources of income replacement for those unable to work, rehabilitative services from the state vocational rehabilitation agency and private sources, and job accommodation for the individual hurt on the job.

We include some questions you may want to use :The students should have read the Workers compensation fact sheet that will be on Medscope, the internal website for notes, etc. (You have a copy in the Additional Materials section of the Instructor Manual.) In addition, Chapters 10 and 11 in Levy and Wegman have a good concise (40 pg. discussion of workers comp, and of social security disability and private disability systems. Even if you are generally familiar with workers comp issues from your job you may learn something from reviewing this material ahead of time. Medical students ( and many physicians) don't know that workers compensation laws prevent employees from suing their employer, that the amounts of workers compensation benefits are strictly limited, and that individuals who get full compensation for an injury or illness take a significant financial loss unless they have other disability insurance. Many have heard compensation described as a get rich scheme for malingering patients. If this misconception doesn't come up spontaneously smoke it out by playing the devil's advocate. Don't a lot of workers exaggerate their injuries so they can sue their employers for a lot of money? How can a doctor avoid being taken in ?

Make sure that the students recognize that help is available from most employers or their workers compensation carriers for job modification or alternative job placement. There is a brief discussion of the Americans with Disabilities Act at the end of Chapter 11 to supplement the short version in the fact sheet. (See Additional Materials section.) We will also have other fact sheets about rehabilitation and return to work.

What happens if the worker can't return to his or her previous job after an injury?
How can the doctor predict this?
What should the doctor do about this and when?
Does the employer have any obligation to help the patient find work he or she can do?

9:20 to 9:40
The practicing physician's role in preventing occupational and environmental illness

Until now the morning's discussion has been mostly about caring for a patient after the fact. We want to use the rest of this morning to discuss how occupational and environmental illnesses can be prevented. The discussion may have already spontaneously turned to preventive resources, including the roles and responsibilities of the employer, of unions, of the health department and MDE, and of MOSH. If not turn the group to these issues for the last part of today's session.
What needs to be done to prevent other individuals from being affected?
Talk about your patient from session 1, as well as the patients in the video. How could these illnesses have been prevented? Should there have been substitution of safer materials? Better engineering controls? Personal protective equipment? a Medical surveillance program ? Should the work process have been altered in some other way?
Whose responsibility is it to do this?
What rights and responsibilities does the individual worker have? The supervisor? The employer? A union? Where do government agencies come into the picture? Review the different roles of the health department, of MDE, of OSHA.
How does the practicing physician fit into this picture?
What do the government agencies and programs set up to prevent disease and injury need from practitioners?
Most small groups will have a student or two whose devotion to the strictly biomedical model of healing makes him or her skeptical whenever we look at medicine in a social context. You may get the next discussion going by ensuring that he gets his say. You can also start the argument yourself:
Isn't the prevention of occupational disease really the responsibility of employers, of unions and of the public health agencies?
Do practicing physicians really need to be involved?
This is an area where resource and primary instructors may want to (sparingly ) use examples from their own work to highlight the critical need we have for more and better input from practitioners.

You may also want to spark some explicit discussion of:
Why should we be learning about this?
How common are work related injuries and illnesses?
Are you really likely to run into these sorts of patients in your future practice?
The students should have some data from fact sheets and from their reading, some statistics are available in the introductions and tables in chapter 1 and chapter 7 of Levy and Wegman. You can direct and challenge the group by asking:
Are there specialties that don't need to know how to deal with these issues?
You'll find that the students can likely think of at least one condition for every subspecialty:If you have time and want to summarize:
Let's list the practicing physician's responsibilities to the patient, what do our patients want from us and what do they have a right to expect?
Each group may approach this in a different way, but most will identify that physicians should: What responsibilities do we have to the patient's employer?
with the patient's permission and while maintaining confidentiality, the physician should:What responsibility do we have to the community?
Let's review the roles of the various agencies and resources and how we interact with them.
The students will almost certainly see the need to get appropriate resources mobilized to identify and correct any hazardous conditions identified. You may want to point out that in Maryland physicians are required to report suspected occupational illness to MDE.

In addition, students may want to discuss what obligation and opportunity health professionals have to get involved in public policy making about occupational and environmental health issues, and issues of prevention in general (tobacco, highway safety, firearm safety, etc.)

AGENCIES and RESOURCES

OSHA: Occupational Safety and Health Administration

What is OSHA? The Occupational Health and Safety Act of 1970 created two new Federal agencies, OSHA in the Department of Labor to enforce safety and health rules or standards and NIOSH in the Department of Health and Human Services to research and investigate occupational health and safety. The Act intended the two agencies to work together, with NIOSH charged with conducting research and, based on its research findings, advising OSHA on what new rules to promulgate. The OSHA Act was a response to public concern about the toll of occupational diseases, symbolized by the epidemics of occupational cancer uncovered during the 1960s. It followed the Coal Mine Health and Safety Act of 1969, and replaced what had previously been spotty Federal involvement with safety in Federally regulated areas and in government contracts. Many states that had regulated workplace safety gave up that function with the passage of OSHA, but other states chose the option of running their own programs integrated within the federal OSHA framework. The Maryland OSHA program (known as MOSH) is an example of a state program. States have the ability to adopt their own regulations, which must be at least as strict as the Federal OSHA rules, and can be stricter.

How does OSHA work? OSHA inspects workplaces on a random basis to assure compliance with its standards. Because of very limited staffing, it is estimated that OSHA could send one inspector for one day to inspect every regulated workplace once every 200 years. Most of the agency's inspections are in response to complaints about unsafe conditions made by employees. When complaints are received, an OSHA inspector will visit the workplace and assess compliance with existing OSHA rules. In addition to enforcing explicit rules, OSHA can intervene on obvious hazards which were not foreseen by the rule book. In doing so, it uses the OSHA law's requirement that employers have a "general duty" to keep the workplace safe. OSHA can compel an employer to correct unsafe conditions by the use of fines, and in the case of "imminent danger" can actually order a dangerous operation stopped. The employee filing the complaint can request anonymity, and is protected from discrimination because of exercising rights under OSHA.

Maryland OSHA welcomes referrals from physicians and health agencies. In recent years, OSHA has shifted its emphasis from enforcement to voluntary compliance programs. This shift has been widely criticized by the public health community.

How does OSHA set its standards? OSHA adopted a set of industry standards on safety and on chemical exposures when it started in 1970. It has moved slowly to update these basic standards and add new rules. The process is supposed to begin by having NIOSH indicate "criteria" for new safety and health rules. After studying this OSHA proposes a rule and accepts comments and criticisms from industry, labor and others in a public hearing process.

How well is OSHA working? Industry has successfully used political influence within the executive branch as well as the federal courts to slow the rule making process. NIOSH produced many dozen "criteria documents" in the 1970s which have been gathering dust, not protecting workers from safety and health hazards. Lacking any strong lobby for safety, despite attempts by labor and public health professionals, OSHA efforts to make its rules fit newer scientific evidence about chemicals have been hamstrung. Recently there has been strong pressure from Congress to keep OSHA from developing rules about ergonomics (workplace design and methods). Attempts have been made to prohibit OSHA from even collecting incidence data on cumulative trauma disorders.

Enforcement is also limited by the low level of funding and staffing for the agency. This has made routine inspections quite rare. Even in cases where OSHA finds violations and orders improvements, it rarely does follow up inspections. OSHA has a responsibility to communicate with workers and union representatives. Sometimes this does not happen as OSHA too often sees itself in a bilateral relationship with the management of the companies it regulates. It relies on management to communicate to employees and almost never speaks directly to affected workers about its decisions or to the public in general.

To learn more: read Chapter 9 in Occupational Health, Levy and Wegman eds. and its accompanying bibliography.


ADA :The Americans with Disabilities Act

What is ADA ? The Americans with Disabilities Act was passed by Congress in 1990 to promote the independence of individuals with disabilities. It enlarged and changed public policy regarding employment in some basic ways.

How does ADA affect employment ? ADA prohibits discrimination against a qualified person with a disability on account of his or her disability in hiring, training, promotion, discipline, and pay. An individual is regarded as having a disability if he or she has a physical or mental impairment that limits one or more major life activities, has a record of such impairment, or is perceived as having such an impairment. Employers must make "reasonable accommodation" to allow a qualified person to work.

What happened to pre-employment physicals? They are history. ADA prohibits medical examinations or inquiries into disabilities until after a job applicant is made a conditional offer of employment. After the offer, an employer can require examinations and may make inquiries about impairments, as long as this is done with all applicants. At that point an employer can withdraw the job offer only if:Where does the physician come in? The employer will need the physician's input to decide if the individual has a disability, how it might be accommodated, and whether there is a real threat to safety in placing an individual in a specific job. Physicians may also need to advocate for their patients who have disabilities.

What's reasonable accommodation? Coming to a decision about this needs to be individualized to a specific person and a specific task. Often ability to do the essential functions of the job needs to be evaluated by job simulation or a job trial. Sometimes physicians may be able to make some suggestions about alterations in task or layout that will make it possible for a worker to function successfully. Some possible accommodations might be truly impractical, but a reasonable accommodation isn't limited to what's immediately at hand or convenient.

To learn more: read Chapter 11 in Occupational Health, Levy and Wegman eds. and its accompanying bibliography.


NIOSH: National Institute of Occupational Safety and Health

What is NIOSH? Set up in 1970 by the OSHA Act, the National Institute of Occupational Safety and Health is part of the Centers for Disease Control in the U. S. Public Health Service. It conducts investigations of specific work related hazards, does surveillance on industry-wide patterns of illness, and funds and performs research about occupational diseases and injuries. In addition it is charged with providing OSHA with information to be used in developing occupational health standards.

How does NIOSH work? NIOSH will conduct a Health Hazard Evaluation (HHE) when called upon by an employer, employees, or local health officials concerned about a health problem in a workplace. Such HHEs are especially useful when the cause of illness in not understood, or where there are concerns and no applicable OSHA rule to follow. An interdisciplinary NIOSH team usually headed by an Epidemic Intelligence Service (EIS) officer will come to the workplace and conduct an investigation using a variety of methods. A report with recommendations will be provided to the concerned parties. NIOSH has no power to enforce its suggestions, but because all concerned parties are aware of them, they are usually followed.

In addition to HHEs, NIOSH conducts long term research on patterns of morbidity and mortality, and on mechanisms of disease. It funds research in other institutions, and tries to develop consensus about research agendas. It funds education and training in occupational safety and health at Educational Resource Centers around the country.

NIOSH actively encourages medical students, physicians in training, and other health professionals to spend elective time with the agency, usually involving participation in one or more HHEs. The University of Maryland offers senior electives at NIOSH offices in Cincinnati, Ohio and Morgantown, West Virginia . (NIOSH also has a toll free information hotline to assist health professionals with technical information
( 1-800-35-NIOSH ).

How is NIOSH working? NIOSH has never enjoyed a very large budget, but has played a pivotal role in the development of the field of occupational health and safety. While OSHA has been dominated by safety experts, engineers, and lawyers, NIOSH has provided a medical and epidemiological approach to workplace safety and health. Freed of enforcement powers, it has been able to make recommendations that are often very influential. NIOSH was targeted for elimination, but survived. Due to financial pressures over its nearly thirty year history, it has had to retrench and close many regional offices, and reduce its funding for training and research.

After conducting a series of meetings throughout the country to solicit input on research priorities for the occupational health and safety community, in 1996 NIOSH developed the National Occupational Research Agenda (NORA) to provide a framework to guide health and safety research in the next decade. The 21 NORA Priority Research areas are listed below.

To learn more: read Chapter 4 in Occupational Health, Levy and Wegman eds. and its accompanying bibliography.


Workers Compensation

What is workers compensation ? Workers compensation is a system of insurance that provides injured workers compensation for lost wages and medical expenses when they are injured on the job. In the first two decades of this century, lawsuits by individuals injured by dangerous working conditions drew public attention and outcry. Legislatures in every state, and the Federal government set up worker compensation laws that embody the "historic compromise" of workers compensation. Workers gave up their right to sue for negligence when hurt on the job, and in return gained a system of insurance that would cover lost wages and medical bills for all injuries, even those where negligence was not involved.

How does it work? The rules of the system vary from state to state, and are different for the various Federal systems for Longshoreman and harbor workers and for Federal employees. In general, workers must notify their employer of an injury in a timely manner, and the employer or worker or the treating physician notifies the workers compensation commission. In most states (including Maryland) employers are either self insured or pay for insurance coverage from a private insurance carrier. In a few states there is a centralized state run insurance fund. As long as the worker and employer agree that the injury occurred on the job, or that the illness was caused by the job, the worker's medical bills are paid and a percentage of lost wages are replaced. These compensation benefits are always less than the worker's regular pay, but are not taxed.

What if the worker and employer don't agree? If the employer or insurance company "contest" or challenge the work relatedness of the injury, or the need for the worker to be off work, or the need for some aspect of treatment, these disagreements are settled at a hearing. If the worker is off work and asking for "temporary total" compensation, he can ask for an emergency hearing. At the end of the process, when the patient has made as complete a recovery as expected, he can be compensated for any residual impairment that could result in loss of future earnings. In such a dispute the worker can be represented by a lawyer whose fee is paid in addition to whatever compensation is decided. Awards for loss of future earnings are fixed, and there is no compensation for pain, suffering, or effects on marital life, even in situations of employer negligence.

What does the physician need to do? The physician can file a "first report of injury" with the compensation system to get the process started. He or she will be asked to provide written reports of the patient's treatment and progress, and to document whether the patient can return to work. Most employers will make any necessary accommodation to allow an early return to work after an injury. Getting back to some kind of productive activity as soon as possible after an injury is an important morale boost for most patients. The physician may be asked to assess a percentage of "permanent partial" impairment after the patient has reached their maximal recovery. This assessment is usually made following the AMA Guideline to the Evaluation of Permanent Impairment.

How well does workers compensation work? No one likes the way workers compensation works. Employers and insurers feel that workers are encouraged to claim that some problems (especially back problems) are work related in order to get medical bills paid and income replacement. (The United States is unique among industrialized countries in the high percentage of workers with no health or disability insurance.) The extent to which this cost shifting takes place, or that costs are shifted to regular health insurance by injured workers and/or their physicians who don't want to bother with workers compensation, has not been measured.

Injured workers are frustrated by their financial losses ( an injured worker never gets as much as they would have made by continuing to work) and by delays in receiving benefits. In Maryland, insurance companies have almost total control over the process. Even after a commissioner has ordered compensation provided, an insurer is permitted to refuse to pay for specific treatment, or to cut off benefits whenever it feels the employee could return to some sort of work. A worker out of work and without income from an illness or injury can wait six months for an "emergency" hearing to correct such decisions. This power to delay allows insurance carriers to negotiate compromise settlements in which injured workers settle for less than what the rules provide in order to end such delays.

Physicians are frustrated by delays in payment for services and by additional demands for written reports. (One fear is unwarranted: treating physicians are almost never asked to appear at hearings in person). These frustrations tend to channel medical care for injured workers to physicians who are selected by the employer or insurer, rather than to or through the patient's family physician. In some states, including Maryland, efforts are underway to provide all care for job injuries through employer-selected providers or HMOs in order to contain costs and reduce lost time.

To learn more: read Chapter 10 in Occupational Health, Levy and Wegman eds. and its accompanying bibliography.


TOSCA: The Toxic Substances Control Act

What is TOSCA? The Toxic Substances Control Act was passed by Congress in 1976, in response to public outcry over episodes of human poisoning from industrial chemicals. Of particular concern were situations involving human exposure to substances whose toxicity had been inadequately evaluated as well as cases in which hazards were known, but workers and government agencies were not informed. The Act empowers the Environmental Protection Agency (EPA) to regulate chemicals to prevent "unreasonable risk to human health or the environment".

How does TOSCA work? Manufacturers of chemicals are required to give the EPA a pre-manufacturing notice (PMN) before producing a new industrial chemical or making a new use of an existing chemical. The EPA can then review existing information and decide whether to require the manufacturer to do further toxicological studies, to require certain labeling, or even to ban the proposed manufacture or use.

How has TOSCA worked? EPA has moved cautiously in using the powers granted to it under TOSCA. During the first 13 years of the act it took regulatory action only 22 times on existing chemicals, and 15 of these actions involved only one family of substances the polychlorinated biphenyls (PCBs). EPA's powers have been attacked in court on a number of occasions, and the agency was generally unassertive during the 1980s and 1990s. On the positive side it has made it clear that while manufacturers and users of industrial chemicals can protect legitimate "trade secrets" they may not withhold information about possible health hazards.

To learn more: Read Chapter 9 in Occupational Health, Levy and Wegman eds. and the accompanying bibliography.


Right to know Hazard Communication rules

Do workers have a Right to Know? Prior to 1980, there was considerable dispute in law and in practice about how much a worker had the right to know about the hazards of his or her work. When employers conducted medical surveillance programs, they commonly kept workers ignorant of the results of medical examinations. In some cases they justified withholding information by the desire to avoid worrying the worker about conditions that couldn't be treated. Workers were denied access to company medical records and data about exposure to chemicals. Workers were not regarded as even needing to know the identity of chemicals with which they were working. Some courts held that employers had to share information with unions during bargaining, but no responsibility to inform was established.

What are the current rules? In 1980, OSHA issued a general Access to Medical Records requirement opening up company records about exposures and medical surveillance to the affected workers and their physicians. This enlarged the policy of openness that OSHA had previously pursued in its regulation of specific substances like asbestos and lead. In response to episodes of poisoning and pollution, and to the weakening of federal OSHA under President Reagan, campaigns were begun by local labor and environmental groups in cities and states around the country to assert worker and community right to know. These campaigns were vigorously resisted by industry, but it was hard to make cogent arguments in favor of more ignorance and deception. More and more jurisdictions (including Maryland) passed regulations. Finally the chemical industry called on OSHA to promulgate uniform ( and weak) rules for the whole country to supersede strict local rules. OSHA issued a Hazard Communication standard which initially exempted many employers and situations. Federal courts later required it to be broadened to most industries and made it clear that state laws requiring community right to know could still be enforced.

What do workers have a right to know? The Hazard communication standard requires that workers be trained about their right to obtain information, how to obtain information, and about the specific chemical hazards to which they might be exposed. They must be trained in how to detect the presence of hazardous chemicals, the hazards of the chemicals, and how to protect themselves. It requires chemical manufacturers to prepare and provide Material Safety Data Sheets MSDSs to accompany hazardous materials and to appropriately label chemicals.

How does it work? MSDSs must be kept in the workplace and be made available on request to employees. In addition, all employees are to be trained in specific classes about chemical hazards and right to know rules.

How is right to know working? OSHA has made checking on compliance with hazard communication a priority in all its inspections, and many workplaces are trying to comply. The requirement for specific labeling and MSDSs has dramatically increased the number of people who see at least some warning about hazards for toxic chemicals. This new philosophy about free flow of information has had major impact on use of chemicals. It has put increased pressure for provision of safe work practices, and in many situations has stimulated the choice of safer materials or practices. Along with TOSCA, Superfund and SARA regulations, and the Toxic Release Inventory, right to know rules have begun to change American businesses' attitude and approach to the use of chemicals, and provided economic incentives for environmentally sound decision making.

Major drawbacks to the effectiveness of right to know are the general incomprehensibility of MSDSs in their present form, the absence of quality control for the data contained on them, and the total reliance on manufacturers and employers to be the bearers of bad news. The regulations didn't set up any other mechanism to independently enhance knowledge about the workplace and environmental impact of chemicals, about safe methods of use, and about decision making.

To learn more: read Chapter 9 in Occupational Health, Levy and Wegman eds. and its accompanying bibliography.


Rehabilitation of the injured worker

What is vocational rehabilitation? Rehabilitation is the process of assisting an injured or ill worker to return to functioning successfully at home, in the community and at work. The goal of rehabilitation is to restore the highest achievable level of function in each of his or her roles, as breadwinner, as family member, and as citizen. Rehabilitation professionals work in multi-disciplinary teams including physicians, nurses, physical therapists, occupational therapists, vocational counselors, psychologists, and specialists in adaptive technologies. Physiatry or Rehabilitation Medicine is the medical specialty which focuses on the rehabilitation of patients, but other physicians often play a major role in their own patient's recovery.

How does vocational rehabilitation work? After an illness or injury that changes the patient's functional ability, the physician may need to mobilize resources to aid with rehabilitation. Every state has a state agency like Maryland's Division of Rehabilitation Services (DORS) that can evaluate an individual and provide needed assistance. DORS can provide special training, adaptive devices, modifications to the home or vehicle, and above all sympathetic and supportive professionals to work with patients and their families. In addition to DORS, there are many private rehabilitation professionals, as well as rehab hospitals and outpatient facilities.

Who should refer the patient? The physician should make an initial referral as soon as there is a likelihood that the patient may not be able to return to full function at home or to the same job activity at work without special help. This includes those patients who may make a good recovery physically but will need to change jobs or job assignments because of an illness or injury. In many cases, the workers compensation insurance carrier will involve a private vocational counselor or rehab nurse to assist the patient after a serious injury.

How well does vocational rehabilitation work? Physicians are often the greatest stumbling block to successful rehabilitation, when they look only at the medical problems and not the functional problems their patients are having. Many patients have unnecessary difficulties, and lose valuable time in their recovery, because their physicians are slow to refer. In general, state agencies such as DORS provide the most thorough and comprehensive services, but sometimes there are delays because of lack of resources. Workers compensation insurers prefer to hire and direct private rehab agencies, but this can lead to a conflict of interest. Sometimes there is a pressure to return the worker to any type of work as soon as possible, and with the fewest short term costs for the insurer. In contrast DORS tends to develop a client centered plan that focuses on achieving the highest level of functioning and productivity. In the long run this approach is the most economical for society as a whole.

To learn more: read Chapter 10 and 11 in Occupational Health, Levy and Wegman eds. and its accompanying bibliography.


This document was last modified on 06/14/2000 03:08:02 PM


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