SPECIAL ARTICLE * ARTICLE SPECIAL
Occupational medicine in Canada: An end or a new beginning? John L. Weeks, MD, DIH, MFOM, CCBOM Occupational medicine is frequently described in the broad context of the provision of occupational health services as a whole. Although this approach reflects the concepts currently underlying the delivery of occupational health services in Canada and in other countries, it is sometimes necessary to consider the problems that relate specifically to occupational medicine and to those who practise in this field. In this article some of these problems are discussed and suggestions made as to the way in which occupational medical practice may develop in Canada. On decrit souvent la medecine du travail dans le contexte global de la prestation de l'ensemble des services de sante au travail. Bien que cette approche soit le reflet des concepts qui sous-tendent actuellement la prestation de services de sante au travail au Canada et dans d'autres pays, il est parfois necessaire de considerer les problemes qui ont directement trait a la medecine du travail et a ceux qui la pratiquent. Cet article traite de certains de ces problemes et propose quelques facons possibles de developpement de la medecine du travail au Canada.
In January 1989 the Ontario Ministry of Labour published a report on workplace health and safety in Ontario.' Nowhere in some 70 pages of text, annexes and legislative proposals is there mention of occupational medicine or occupational physicians. The omission may be inadvertent, as the report is concerned mainly with occupational safety and with ways of controlling the costs associated with occupational injuries; none the less, such an omission reflects an attitude toward the role of the occupational physician in Canada today. It may be useful, therefore, to examine the way in which occupational medicine has developed in this country, to consider the problems confronting those who practise in this field and to suggest ways in which the specialty may develop. The discussion is limited to occupational medicine, but it is recognized that this specialty is most often practised as a part of the broader field of occupational health and safety.
Development of occupational health services in Canada In 1984 occupational medicine was recognized as a separate specialty by the Royal College of Physicians and Surgeons of Canada. This action, which brought Canada into line with most other industrialized countries, formalized changes that had taken place during the previous 50 years. During the 1930s occupational medical services were to a large extent concerned with the treatment of injuries occurring at work and were provided mainly by surgeons. During the period immediately after the Second World War the emphasis shifted to the provision of screening services aimed at detecting incipient or actual occupational disease by means of preplacement and periodic medical examinations. Although to some extent such services were perceived as employment benefits, this was no longer
Dr. Weeks is senior adviser on health and safety at Whiteshell Research, Pinawa, Man.
Reprint requests to: Dr. John L. Weeks, Whiteshell Research, Pinawa, Man. ROE JLO CAN MED ASSOC J 1990; 142 (3)
the case after the introduction in Canada of universal medical care. Provision of occupational medical services was often the responsibility of family physicians employed on a part-time basis by local industries, but after the '50s such services increasingly were provided by full-time occupational physicians, many of whom had obtained postgraduate qualifications in occupational medicine. However, part-time practitioners still constitute the majority of those practising occupational medicine, and this has a bearing on the accreditation standards that have been developed. While these changes were taking place in the practice of occupational medicine, developments were also occurring elsewhere in the occupational health and safety field. The role of the occupational health nurse, the industrial hygienist, the toxicologist, the safety professional and the biostatistician expanded such that the occupational health program of the '80s bears little similarity to the surgical and medical services provided to industry some 50 years ago. The modern program depends on the involvement of well-qualified people in many professions and is geared to the prevention of occupational injuries and disease rather than to detection and treatment.
Issues in occupational medicine Many current trends in occupational medicine are products of the social changes that have taken place in Canada during the past 30 years. An important issue confronting occupational physicians in Canada and elsewhere is credibility. Unions have expressed their deep mistrust of physicians employed in the private sector and in several instances have set up clinics to provide alternative and parallel services for their members. Unions are little more trusting of physicians employed in the public sector, and a senior union official in Canada has stated that "our purpose is to ensure that all of our members can attend occupational medical clinics that are completely controlled by the unions". It is questionable, however, that the replacement of the "company doctor" by a union-controlled physician would necessarily be in the best interests of the work force. Occupational medicine must occupy neutral ground, and the answer to a medical question should not differ whether it is asked by employee, management or union. It is not unusual for pressure, either direct or indirect, to be exerted on physicians by any of the parties involved, but in general such pressures are effectively resisted. However, the exceptions to this statement, although not justifying the position of organized labour, at least make that position understandable. The way in which the question of credibility is resolved will have a major bearing on the 216
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development of occupational medicine in Canada during the next 10 to 15 years. It is important in this context to recognize that some unions perceive occupational health and safety as an area in which there is likely to be room to move during bargaining sessions. To an occupational health care professional it is anathema that any aspect of the discipline should be used as a bargaining counter, but it is prudent to recognize realities. A second important issue in the past decade has been the development in Canada of ways in which qualified and competent occupational health physicians can be formally accredited. The lead agency in these efforts has been the Canadian Board of Occupational Medicine (CBOM), which has developed an examination program leading to certification (CCBOM) or associate membership (ACBOM) for occupational physicians who meet the board's eligibility requirements. In 1984 the Royal College of Physicians and Surgeons of Canada instituted an examination program for occupational medicine leading to fellowship, the most senior medical qualification available in Canada; the first examinations were held in 1988. Such accreditation programs will provide assurance to employers and employees that a physician has achieved a certain level of competence and will improve credibility. However, credibility will likely remain an issue as long as occupational medicine is practised in the adversarial context of labour-management relations; recognition of this may point to a way of resolving matters in the future. The introduction of occupational health and safety legislation at federal and provincial levels together with enforcement of the resulting regulations has codified some minimal standards of good practice in the field. These standards are not remarkable, and for many years before the legislation their requirements had been exceeded by well-organized programs. Prominent among legislative issues is the right of an employee to know that he or she is working with hazardous materials or in a potentially hazardous situation. This concept is not new - it was expressed very clearly by Legge2 in 1934 - but implementation has in the past been hampered by questions of commercial secrecy. "The right to refuse dangerous work" has been described by some as "the right to strike within a contract". Some incidents do serve as a basis for such allegations, but in general "the right to refuse" has not been abused and, when intelligently applied and responded to, has been instrumental in the development of a degree of confidence between employees and management. Problems involving occupational physicians, management and the work force have arisen in a number of other areas, such as medical surveillance,
confidentiality and custody of medical records, invigilation of sickness absence, testing for the abuse of drugs, AIDS (acquired immune deficiency syndrome) in the workplace and reproductive hazards in the workplace. These are complex issues, and in resolving them the occupational physician and nurse will find themselves involved in roles far removed from traditional concepts. The ways in which these roles are integrated within the occupational health service as a whole have been described,3 and guidance to the management of the problems that can occur is found in a recent CMA publication.4
The practice of occupational medicine Among those who practise occupational medicine there is concern that the community perceives a decreasing need for the work of this specialty, that in the face of the rapidly developing role of occupational health and safety as a whole, occupational medicine is obsolescent, if not obsolete. A prudent response to this situation is to examine with care the question Is occupational medicine necessary? Some occupational physicians are employed in factories, some by major corporations. Others work for union clinics, for government agencies or in an academic setting. Some are employed on a full-time basis, but in Canada most occupational medical services are provided by part-time practitioners. The words "are employed" have a particular significance, for they describe the position of most occupational physicians no matter where they work and thus have a bearing on the question of credibility. Even when a physician provides occupational medical services as an independent contractor, the physician is still to some extent dependent for a livelihood on those to whom a service is provided. There is no particular mystique to occupational medicine; it is no more or less than the application of general medical principles of the broadest type to the specific conditions of the workplace or, more accurately, to many different workplaces. Whether a physician has a particular interest in diseases of the blood, in respiratory disease, in epidemiology or in neurology, the basic concepts of pathology, diagnosis, assessment and management in occupational medicine are no different from those in any other medical field. This is borne out by the fact that both the CBOM and the Royal College require a good basic education in clinical medicine as a prerequisite for their examinations. What is different about occupational medicine is that to practise it effectively one must have a very specific and detailed knowledge of the workplace and working conditions in relation to which a certain clinical problem is being considered. To acquire such knowledge it is necessary to talk and listen to
workers and to look around the workplace with enough background knowledge to know what one is seeing. At the end of one site visit the occupational physician should have learned something about the working conditions of one group of people. After dozens or maybe hundreds of such visits the occupational physician should have acquired such a large background of knowledge about work environments that it is reasonable to use the word "expert" in relation to that person's practice in occupational medicine. It is the application of the basic principles of medical practice in the context of expert knowledge of many different work environments that makes occupational medicine a specialty and that ensures a continuing need for this type of expertise. Is it then necessary that the occupational physician be based within one work environment? To some extent the answer to this question depends on the type of work being done by the physician. Broadly speaking, this work falls into two categories: the provision of occupational medical services (i.e., the provision of medical care in the workplace) and research and administrative work related to the wide field of occupational health and safety. At present a large part of the occupational medical services available in this country are provided by independent medical contractors who are not employees as such of the companies to which the services are provided and who are usually based outside the workplace. Developments in Quebec have provided a new perspective to the provision of medical services to industry by occupational physicians, some of whom are government employees on the staff of the Departement communaute sanitaire in many localities and have no administrative relationship to industrial employers. In theory this approach is a good indication of the way in which occupational physicians may become free of the constraints perceived to be imposed by a master-servant relationship that exists between physician and employer. That many occupational physicians in Canada continue to practise in a full-time relationship with private companies and corporations is a matter of record. There have been indications during the past decade that this form of practice is on the decrease. Retirees have not been replaced, contracts have not been renewed, medical staff have been "let go", and existing medical services have been disintegrated into small groups scattered among the operating subsidiaries of major corporations. It is questionable whether employers are prudent to pursue "bottomline accounting" in relation to their medical services, but corporate medical services unquestionably are an expensive item for which it is not always easy to produce convincing cost-benefit analyses. Employerfunded occupational medical services are therefore CAN MED ASSOC J 1990; 142 (3)
vulnerable at a time when comparable, seemingly adequate services are obtainable from sources outside the corporation, such as private occupational medical clinics, individual physicians or groupings of emergency department physicians; the last is a curious reversion to the system of the 1930s. If indeed there is a trend toward the demise of the corporate occupational medical service, this is not a disaster for the newly fledged specialty. More importantly, such a demise need not detract from the quality of medical service available to the employee on the shop floor or in any other work environment. Occupational medical services continue to be provided quite apart from any regulatory requirement, and it may be concluded that the community does in fact regard such services as necessary.
The way ahead There are several players in the arena of occupational medicine. Physicians who practise occupational medicine, whether full-time or part-time, are making a determined effort to upgrade their qualifications and to improve standards of practice. Employers are increasingly reluctant to spend money on programs that are undeniably costly, and organized labour, distrusting health and safety programs provided by employers, is developing parallel services operated by provincial union federations but funded in part by provincial governments (i.e., by the taxpayer). On the periphery is the "walk-in clinic", which, together with the hospital emergency department, provides some of the acute medical and surgical services for work-related injuries. Each of these participants could quite easily go its own way, and some might thrive in so doing, but it is questionable whether the community as a whole would under these circumstances be well served. Research and educational facilities are no less important to occupational medicine than to other specialties. Little in-house research on occupational health as a whole is undertaken by large corporations in Canada. A certain amount of extramural research, most of it located in universities, is funded by major employers. Research is also funded by the federal government, unions and provincial governments. Therefore, there is in effect a tripartite approach to research, which, even though uncoordinated, may contain the concept by which occupational medicine will be practised in the future. With the availability in Canada of specialist qualifications in occupational medicine, the question of educational facilities becomes increasingly important. At the undergraduate level formal training in occupational medicine ranges from little to none at all. In a recent editorial Snashall5 described the basic occupational health knowledge required by a gradu218
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ating physician; few would disagree with these requirements. Those who opt for a career in occupational medicine, either full-time or part-time, require further education, and the facilities currently available in this country are limited, although greatly improved over the past decade. At the time of writing, three medical schools in Canada are preparing residency programs in occupational medicine; it is, however, necessary to determine with some accuracy the number of residency places required to meet future needs for occupational physicians in this country. In these three areas - delivery of services, research and education - occupational medicine has arrived at a point of major transition. There is a growing perception that the needs can best be met by a well-coordinated and cooperative tripartite effort on the part of employers, unions and government. The extent to which this can be achieved at the organizational level has been demonstrated by the Canadian Centre for Occupational Health and Safety, but a much wider approach is needed. In the delivery of occupational health services a tripartite effort at the community level would do much to meet pressing needs, in particular those of small industries, while at the same time resolving the problems of credibility. An occupational physician employed by a community occupational health unit funded by employers, unions and government would not be free of all pressures, but at least the credibility issue would be reduced to manageable proportions. The approach to occupational health research is already in effect tripartite, but cooperation and coordination are needed if maximum results are to be achieved for the funds expended. Education in the field is largely a matter for universities. The immediate requirement is to assess the number of occupational physicians who must be trained if the needs of the community are to be met. Training can be provided through full-time and part-time courses, workshops, seminars and distance-learning courses. Much is being done, but coordination and assessment are urgently needed. It is improbable that more can be achieved unless funding is available, and the source of such funding is likely to be the three groups who are the main customers for the skills to be developed. Those who have followed events at all closely will recognize that what is being proposed is an approach to occupational medicine similar in many respects to that already established in the Scandinavian countries. No system can be transferred as is from one country to another, but the high repute of occupational medicine in these countries strongly suggests that an effort should be made to determine how the Scandinavian approach could be adapted to Canadian needs.
tional medical services, together with increasingly strict requirements for the accreditation of those who practise in the field. During the next decade it can be expected that in Canada, as in other countries, there will be important changes in the practice of occupational References medicine. Such changes are already apparent in many areas. The fact that conditions will be different 1. New Directions in Workplace Health and Safety in Ontario. A Background Paper, Ont Ministry of Labour, Toronto, 1989 from those experienced by professionals who entered 2. Legge T: Industrial Maladies, Oxford U Pr, London, 1934. the field 30 or more years ago is not a sign of Cited in Hunter D: The Diseases of Occupations, 2nd ed, terminal disorder. It is, rather, evidence of the English Universities Pr, London, 1957: 221 viability of the specialty and its ability to adapt to a 3. Cowell JWF: Organization and management of occupational health and safety programs. Occup Health Ont 1985; 6: 75-86 changing environment. Occupational medicine will 4. Provision of Occupational Health Services - a Guide for develop in its technical aspects as it has done since Physicians, CMA, Ottawa, 1988 the early years of this century, but the main changes 5. Snashall D: Undergraduate teaching of occupational health [E]. Br JInd Med 1989; 46: 433-434 will be in the administration and delivery of occupa-
continuedfrom page 212 Apr. 18-21, 1990: Aging into the 21st Century Ottawa Congress Centre Christine Blais, Conference Office, School of Human
Kinetics, University of Ottawa, 123B- 125 University Priv., Ottawa, Ont. KIN 6N5; (613) 564-9291 Apr. 22-24, 1990: Canadian Life Insurance Medical Officers Association 45th Annual Meeting L'Hotel, Toronto Dr. Thomas Porter, president, Canadian Life Insurance Medical Officers Association, c/o medical director, Imperial Life Assurance Company of Canada, 95 St. Clair Ave. W, Toronto, Ont. M4V 1N7; (416) 926-2690
May 6-9, 1990: Association of Records Managers and Administrators 6th Canadian Records Management Conference Halifax World Trade and Convention Centre R. Dagenais, Export Development Corporation, 151 O'Connor St., Ottawa, Ont. KIP 5T9; (613) 598-2500 May 12-13, 1990: International Advanced Life Support
Competition Edmonton Inn Mr E. Moffatt, Alberta Prehospital Professions Association, 8711-50th Ave., Edmonton, Alta. T6E 5H4; (403) 268-9703 May 13-17, 1990: Interphase EMS Society Annual
Meeting Edmonton Inn Ms. J. Osborne, Alberta Prehospital Professions Association, 8711-50th Ave., Edmonton, Alta. T6E 5H4; (403) 469-2760
May 15-18, 1990: Catholic Health Association of Canada Annual Convention Victoria Conference Centre and Empress Hotel, Victoria Freda Fraser, director of communications, Catholic Health Association of Canada, 1247 Kilborn Ave., Ottawa, Ont. K1H 6K9; (613) 731-7148, FAX (613) 731-7797
May 19, 1990: Practical Approaches to Adolescent Medicine Victoria Conference Centre Mary Ransberry, Conference Office, University of Victoria, PO Box 1700, Victoria, BC V8W 2Y2;
(604) 721-8465 May 20-25, 1990: 8th International Congress on Circumpolar Health - Community Health: Problems and Solutions in the North Yukon College, Whitehorse 8th International Congress on Circumpolar Health, 801 750 Jervis St., Vancouver, BC V6E 2A9; (604) 681-5226, FAX (604) 681-2503
May 22-24, 1990: 3rd S.M. Dinsdale International Conference on Rehabilitation Ottawa Congress Centre Education Department, Rehabilitation Centre, 505 Smyth Rd., Ottawa, Ont. KIH 8M2; (613) 737-7350, ext. 602; FAX (613) 737-7056
May 24-25, 1990: 3rd Annual Health Policy Conference: Producing Health - Implications for Social Policy Queen's Landing, Niagara-on-the-Lake, Ont. Ms. Lynda Marsh, conference administrator, Centre for Health Economics and Policy Analysis, McMaster University, 1200 Main St. W, Hamilton, Ont. L8N 3Z5; (416) 525-9140, ext. 2135; FAX (416) 577-0017 May 24-26, 1990: Celebration 1990: a National Conference for Deaf and Hard-of-Hearing People (presented by the Canadian Hearing Society, the Canadian Association of the Deaf and the Canadian Hard of Hearing Association) Holiday Inn Downtown, Toronto Susan Carbone, conference coordinator, Celebration 1990, Canadian Hearing Society, 271 Spadina Rd., Toronto, Ont. M5R 2V3; (416) 964-9595, TDD (416) 964-0023, FAX (416) 964-2066
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