Detecting Occupational Illness
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Lee S. Newman, MD
Director, Division of Environmental
and Occupational Health Sciences
National Jewish Medical and Research Center;
Professor, Department of Medicine and
Department of Preventive Medicine and Biometrics
University of Colorado School of Medicine |
The Workplace: A Source of Preventable Illness
Patients increasingly express the concern that their occupations may adversely affect their health. Studies of general medicine hospital admission support this concern: when patients present with a respiratory or musculoskeletal primary complaint, occupational factors are implicated more than 10% of the time. For example, up to 15% of adult-onset asthma is due to occupational exposures or on-the-job aggravations.
Other statistics reveal that the economic costs of hazardous exposure and injuries on the job have reached more than $60 billion a year. Each year, physicians diagnose 125,000 to 350,000 first-time occupational illnesses. Failure to recognize and prevent these diseases clearly results in expensive, unnecessary health care and inappropriate treatment.
With these data in mind, physicians should consider the patient's occupation in relation to their chief complaint, treating each patient with a work-related illness as a "sentinel health event." With the sentinel approach, recognition of a work-related illness can lead to prevention when the history is traced to the hazards in the workplace that caused it. However, because so few physicians have training in recognizing and preventing such illnesses, they can easily miss the relationship between occupational risks and disease.
The key to diagnosing occupational illness is to begin by suspecting it. The diagnosis may be obvious when the patient presents with an acute traumatic injury; physicians find more difficulty with diagnoses that result from repetitive motion or hazardous exposures that produce delayed latent health effects. Failing to ask patients about their work not only poses the risk of attributing the illness to non-work causes, but may also lead to unnecessary tests and a missed opportunity to protect others at risk in the environment.
Collecting the Evidence: The Occupational Health History
An accurate occupational health history provides valuable clues to identifying relationships between the workplace and the patient's chief complaint. This process does not necessarily require unique knowledge of industrial processes or toxicology. "We recommend including a few simple screening questions in the written medical questionnaire that patients complete prior to the clinical Visit," notes Lee Newman, MD, Director of the Division of Environmental and Occupational Health Sciences at the National Jewish Medical and Research Center (see Table 1 on page 2 for example topics). "A brief chronology of jobs, exposures, and a checklist of hazards can be completed in minutes and reviewed quickly by the practitioner during the examination."
Matching the History to Clinical Assessment
A quick scan of the medical questionnaire will help identify if the current illness might be work related. If the answers suggest a link, use the questionnaire as a guide during the interview and clinical assessment. The next step is simply to add a few brief questions to the medical interview and review of systems (see Table II ).
Hazardous materials can affect any organ or system, but physicians can easily miss the occupational link by not using the occupational history interview and the clinical assessment together. Occupational medicine specialists such as those at National Jewish, through their experience in evaluation, treatment and research of work-related diseases, have learned important-, clues to the recognition of occupational disease by affected system (see examples in Table III on page 3). Even common illnesses can be caused or aggravated by occupational exposures.
These specialists have also discovered specific clues for which to search (see Table IV on Page 5). When asked about the usefulness Of familiarizing oneself with the type of data fund in Tables III and IV, Dr. Newman points to the result of an improved patient-practitioner relationship. " Physicians who Stop to ask their patients about their jobs and concerns about occupational hazards will be rewarded. Patients appreciate physicians who care about what they do and who are conversant with the potential health effects of workers-whether it's an OR nurse with latex allergy or a Pipefitter with pleural plaques from asbestos."
Investigating the Case: A Systematic Approach
Often physicians choose to consult an occupational medicine specialist if their initial evaluation raises suspicions of an occupational exposure. Few in high volume practices have the time or to fully investigate the causal link of the patient's illness to the job site or prevent occupational illness. But, by being able to identify suspicious cases and turn to specialists who can investigate the exposures, toxicology, and industrial and agricultural work conditions, doctors extend their ability to prevent disease in the community.
In the current managed care environment, more and more primary care physicians assume responsibility for the management of those with workplace illnesses and injuries. Thus, these practitioners now have the unique opportunity to start the patient -- and often whole corporations -- on a path to disease prevention.
Occupational medicine physicians at National Jewish suggest a systematic approach if the chief complaint is work-related. First, establish a clear clinical diagnosis, such as the examples of asthma in bakers or bronchitis in coal miners. Then, conduct clinical tests to help exclude non-occupational causes.
Next, turn to available sources for supporting evidence. Major textbooks and Internet sites present the most common environmental causes of particular occupational illnesses. Other resources offer information about specific workplace activities and describe the associated risks, including lists of common chemicals, typical exposures in common jobs, and their potential side effects. For example, the law requires companies using hazardous materials to maintain Material Safety Data Sheets (MSDS). The MSDS lists a particular product's ingredients, any known health hazards, precautions for safe handling, and permitted exposure limits. Occupational Health and Safety Administration (OSHA) regulation requires that employees have access to these sheets; however, they may be somewhat limited or overly generic. The MSDS often helps in identifying acute signs and symptoms rather than long-term health effects of a product. Table V (page 6) lists additional resources.
Occupational medicine specialists at National Jewish expand the initial assessment inquiry by gathering detailed information on past and present exposure, work processes, and specific toxins. To accomplish this assessment, specialists use a team approach, coordinating with industrial hygienists, occupational heath nurses, health and safety personnel, and others at the patient's workplace. This assessment leads to an understanding of the nature and extent of the patient's exposure. The combination of the clinical evaluation and work site assessment leads to appropriate and effective treatment and primary and secondary prevention. Later, documentation from the specialists investigation of a patient's work history can be critical in addressing workers' compensation issues and preventing the unnecessary illness in other workers.
Clinical Management of Occupational Illness
Occupational medicine physicians can provide patients and their medical care providers with clarification of occupational illnesses. Findings and recommendations can significantly influence subsequent decisions about the management of the illness, such as return to work or work restriction. These decisions affect the patient's opportunities for employment, job advancement, earning potential, insurability, and psychological and social well-being in addition to physical health.
- If a physician recommends a work restriction or permits return to work, he or she should first gather enough evidence that such interventions are justified.
- Is the restriction-even if temporary-likely to result in a better health outcome?
- Is return to full work duty safe or will the patient return to unhealthy conditions of re exposure?
- Will the patient lose income or incur additional unnecessary medical expenses and hard ship?
- Has the work site been modified to allow a safe return to duty?
- Does the patient have adequate protective equipment?
- How serious is the illness?
- Has the physician adequately documented the degree of impairment?
With these questions in mind, learn what tasks the worker needs to perform and determine the appropriate timing for return to work. Consider whether the work activities or ongoing or future exposures will aggravate, accelerate, or worsen the illness or condition.
If an exposure to allergens causes the disease and the patient remains in the exposure, then symptoms may worsen and require additional treatment with medication. For example, isocyanate-induced asthma (e.g., in auto body painters) can become life threatening or require unneeded steroids when the patient returns to work in the same plant-sometime,even in a seemingly "non-exposed" job.
Summary
Proper management of work-related disorders also requires an understanding of the workers compensation system. Primary-care physicians and occupational medicine specialists are often asked to determine if the patient has a work-related illness or injury and if this condition has caused either temporary or permanent impairment. Such diagnoses require careful, thorough documentation of medical findings that support the medical conclusions. Reports should document the level of impairment, the effect of the illness on the activities of daily living, any necessary rehabilitation or treatment, and possible work modifications. Physicians must accurately describe and quantify the physical effects of the illness and ideally work with patient and employer to advise them on what modifications would be necessary if the worker were to return to the job. Dr. Newman concludes, "Physicians can help their patients who have work-related illnesses by being aware of their state's workers' compensation system. For example, in most states, this form of insurance should provide for a worker's lost wages, medical expenses, and, in some states, retraining and compensation for economic hardship caused by the job-induced illness. Usually, this applies to both those illnesses caused by work or those that were substantially aggravated by work. Clear and objective documentation by the treating practitioner helps."
References
- Newman, L.S. Occupational Illness. New England Journal of Medicine. 1995; 333: 1128-1134.
