During the 1980s and 1990s, academic occupational and environmental medicine clinics have emerged as a small, yet important source of occupational health services in the United States. These clinics are affiliated with academic medical centres, schools of medicine or schools of public health. The physician staff is composed primarily of faculty members of the academic programmes with principal teaching and research interests in occupational medicine. The main activity of these clinics is to provide diagnostic medical evaluations of potential occupational and environmental diseases, although many clinics also provide routine occupational health services. These clinics play an important role in occupational health in the United States by serving as an independent source of medical expertise on occupational diseases. The clinics are also major training sites for specialists in occupational medicine and recently for primary care physicians.
The Setting
Independent sources of medical expertise on occupational diseases are needed in the United States because employers are legally responsible for providing medical care and lost wages only if it can be demonstrated that an injury or illness is related to work. As noted in previous articles of this chapter, the vast majority of medical care for injured workers is provided by employers either directly by the employer or indirectly through contracts with private physicians, clinics, immediate care facilities and hospital-based programmes. This system of care is quite adequate for workers with acute injuries or diseases because the role of work in causing these conditions is clear. Therefore, it is in the employer’s interest to provide timely and effective medical treatment so that the employee returns to work as quickly as possible. However, the workers’ compensation systems in the United States do not function well for workers with chronic injuries and occupational diseases because employers are not required to pay for medical care unless it can be proved that the worker’s job was responsible for the condition. If an employer contests a compensation claim, the employee or workers’ compensation officials must seek an independent evaluation to determine whether the condition is work-related. Academic medical clinics have served as regional consultation programmes to provide this independent source of medical expertise.
Academic occupational medicine clinics have been able to maintain an independent perspective because few of them depend on employer contracts or similar financial incentives which could represent a conflict of interest in evaluating workers’ illnesses. These clinics typically operate as non-profit-making programmes that absorb some of the cost of medical evaluations as part of their teaching and service mission, since complex diagnostic evaluations are rarely cost-effective to undertake without employer support.
The growth of academic-based occupational and environmental medicine clinics has also come about as a consequence of the growth of academic occupational and environmental medicine programmes in schools of medicine and academic medical centres. Until recently, there was a small number of occupational health programmes in the United States, and virtually all of these were based in schools of public health, emphasizing disciplines such as industrial hygiene, toxicology and epidemiology. The number of academic occupational and environmental medicine programmes in schools of medicine increased substantially during the 1980s and 1990s.
This growth occurred for several reasons. The Occupational Safety and Health Act passed in 1970 created the National Institute for Occupational Safety and Health (NIOSH), which implemented a grant programme to support occupational medicine residency training. Many programmes were developed in schools of medicine and were able to provide residency training with the aid of NIOSH grant support. Another reason for the growth of residency programmes is that the professional accreditation organization for occupational medicine in the United States aimed to increase the field’s stature by making completion of a formal training programme (rather than only experience working in the field), a requirement for certification as an occupational medicine specialist. Residency programmes were also established in response to reports by prestigious professional organizations, such as the Institute of Medicine (IOM), documenting the severe shortage of qualified medical practitioners in the field of occupational and environmental medicine (IOM 1993). Many of the new residency programmes established clinics as training sites for the residency programmes. A large proportion of future specialists in the United States will receive their clinical training in the academic-based occupational and environmental medicine clinics.
Organizational Support for the Clinics
The academic-based clinics typically do not provide profitable, routine employee health services like those of the contract providers, so that institutional support has been essential in sustaining these programmes. Several governmental agencies have played an important role in supporting the clinics. As mentioned above, NIOSH has provided support for occupational medicine residency programmes; this support was supplied through the interdisciplinary Educational Resource Centre training consortiums and later through occupational medicine residency training grants. The National Institute for Environmental Health Sciences (NIEHS) has provided research and training support for academic occupational medicine programmes. Many of the most well-established clinics are affiliated with environmental health research centres supported by NIEHS. The clinics support the mission of the centres by identifying populations for clinical and epidemiological research. NIEHS also established the Environmental and Occupational Medicine Academic Award grant programme in the late 1980s to provide support to medical schools for faculty development in the field. This grant programme has now provided support to faculty in a substantial proportion of medical schools with academic-based clinics. The Agency for Toxic Substances and Disease Registry (ATSDR) which was established by the Comprehensive Environmental Response, Compensation, and Liability Act (Superfund) in 1980 to perform environmental health assessments and enhance professional training for evaluating hazardous substances has given essential support for programme development and related professional educational activities as many of the clinics have begun to address environmental as well as occupational health issues.
Several states have programmes to support occupational health services. The largest programme is the University of California Centres for Occupational and Environmental Health. These centres were established in five University campuses and include multidisciplinary research, training and clinical service programmes. Several other states (e.g., New Jersey, Oregon, Michigan and Washington) also support programmes through state schools of medicine or schools of public health. New York State created a statewide network of occupational and environmental health clinics, most of which are affiliated with academic medical centres. This network of clinics is able to evaluate persons with potential environmental or occupational medical problems even if they are not able to pay for these services. The clinics developed a common database system so that the network can serve as an occupational disease surveillance system for the state.
Professional associations have also provided critical support for the growth of academic clinics. Members of the American Public Health Association (APHA) provided an early focus for communication among the emerging clinics. The support of the APHA served to strengthen the public health and prevention orientation of the clinics. In 1987, members of the APHA occupational medicine clinic committee formed a new organization, the Association of Occupational and Environmental Clinics (AOEC), as a “network of clinical facilities dedicated to research and education, as well as the prevention and treatment of occupational and environmental diseases” (AOEC 1995). The AOEC has developed into a national network of more than 50 clinics, most of which are academic-based clinics. Most of the well-established academic-based clinics are members of the AOEC. The Association enhances communication among the clinics, establishes guidelines for quality of care and patient’s rights, seeks funding support for professional and educational activities and is developing a database system so that information from clinics can be systematically collected and analysed.
Programme Characteristics
As mentioned above, the clinics’ principal activity is to identify work-related and environmental diseases, rather than to provide routine employee health services. Because of this focus, the clinics are different from clinical programmes which provide employer-contracted services (Rosenstock 1982). Professionals in the academic clinics relate to potentially affected workers and community members as their primary clients, rather than the employers. The physicians participate in the medical, social, economic and legal aspects of patient problems. The patient-to-provider ratio is low: the clinics, focusing on relatively low-volume but complex medical cases call for longer and more thorough visits that engage the efforts of physician and patient beyond normal clinic hours.
Because of research and teaching responsibilities, the academic clinics usually are part-time, offering up to several sessions per week. A directory of 41 academic clinic members of the AOEC reported a range of one to 13 physicians per clinic, with 85% of the clinics having two to six physicians (AOEC 1995). Another characteristic is that the clinics use multidisciplinary teams of professionals to improve exposure and toxicity evaluation and to provide prevention and education services. For example, of 41 academic clinics in an AOEC directory, most had industrial hygienists (32), while approximately one-half had toxicologists (22), social workers (19) health educators (19) and epidemiologists (24) on the professional staff (AOEC 1995).
The clinics emphasize a community-oriented service perspective. Most clinics establish professional and community outreach programmes, both to establish a referral network for identifying patients and to provide education to health professionals, workers and community residents. Many clinics establish a worker and community advisory committee in order to provide oversight of clinic activities.
Many clinics maintain computer databases so that the experiences of the clinics can be retrieved and analysed. The databases include patient referral source, occupation and industry code of all jobs (or at least current and/or most important jobs), employer name, exposures, work-related diagnoses, assessment of link between exposures and diagnoses, and demographics (Rosenstock, Daniell and Barnhart 1992). So far data collected by the clinics has not been well coordinated, but the AOEC has developed a common database system so this information should be collected more systematically in the future.
Services
The mix of patients seen in academic clinics varies depending on types of employers and community hazards in the region, even more so than among the contract occupational services, which tend to develop in response to employer needs. The clinics may offer specialized diagnostic services depending on the expertise and research interests of the faculty. Patients may go to the clinics based on the expertise and reputation of the academic programme. A patient will usually present with either an actual disease, wanting to know if his or her job or an environmental exposure was responsible, or with a history of a potentially toxic exposure, wanting to know if adverse consequences will result from the exposure.
The most common occupational diagnoses seen in the clinics, as reported in a recent AOEC directory, were as follows (AOEC 1995): asthma, asbestos-related pulmonary diseases and other pulmonary conditions; carpal tunnel syndrome, repetitive strain, musculoskeletal conditions; and dermatological conditions. Few clinics reported neurological problems as a common diagnosis, and very few saw patients with acute injuries. The most common occupational exposure problems reported involved asbestos, lead or other heavy metals, chemicals and solvents.
The distribution of common environmental diagnoses was different from that typifying occupational problems. The most commonly reported diagnoses were determinations of multiple chemical sensitivity syndrome and “sick building syndrome”, or symptoms due to indoor air quality problems. The most common environmental exposure problems reported involved pesticides, lead, chemicals and hazardous waste in communities.
Patients are referred from a variety of sources—they may be self-referred or have been sent by employers, unions, public health agencies, physicians, lawyers and the workers’ compensation systems. Some referrals are made to the programmes because patients want an independent, high-quality medical assessment. Other referrals concern specific practitioners—often faculty members—who have recognized expertise. Choices leading to these latter referrals may be the outcome of a search that is national or even international in scope.
Academic clinics offer services in addition to evaluation of occupational and environmental diseases. Many clinics perform medical screenings for workers at the request of employers, unions or groups of workers who are concerned about a certain exposure, such as lead or asbestos. The clinics also provide medical surveillance examinations mandated by OSHA or state laws. Most clinics serve as regional resources by providing clinical consultations to workers, community residents and physicians, typically via telephone.
In addition to clinical services, the multidisciplinary staff of the academic clinics provide workplace and community hazard evaluations, sometimes including exposure monitoring. Virtually all of the clinics offer health education and prevention training for individuals, communities and health professionals.
The Future
The future of academic clinics in the United States may be affected by overall changes in the workers’ compensation and medical care systems. The need for independent medical evaluations of occupational and environmental problems will continue, but many states have implemented or are considering changes in workers’ compensation laws to restrict the freedom of workers independently to make their own choices regarding a medical evaluation. There is also a trend to integrate medical care for occupational and non-occupational conditions by a single managed care provider. The clinics will need to respond to the growth of managed care in the occupational health field because the independent approach used by these clinics may be largely excluded from a more managed workers’ compensation system.
To respond to these changes in the medical care system, some academic clinics are establishing affiliations with employer contracted programmes so that the clinics function as a speciality referral programme while the other programmes handle routine cases and medical treatment. Academic clinics may also need to establish affiliations with medical centres supplying primary care, urgent care, rehabilitation services and other specialities in order to lend greater comprehensiveness to the services that will be integrally provided by occupational health care and other medical care. This approach will be taken to increase financial stability through the use of contracts in addition to charging fees for service, and to provide training experiences for physicians, many of whom will practise in those settings.
The challenge for academic clinics will be to maintain their independent perspective while functioning in an integrated, managed care system largely financed by employers. The option of independent consultations will be maintained to some degree because of the regional and national referral patterns based on a clinic’s reputation. Clinical practitioners will also continue to provide expert consultations to individuals and lawyers under the tort system, which is also evolving in the United States, albeit more slowly than is the medical care system. However, even with these sources of support, academic clinics in the United States will continue to need support from governmental agencies and professional organizations to continue their role as independent sources of medical consultation, research and training. The future of many of the academic clinics will depend on whether the federal and state governments continue to support these programmes.