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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters



Safeguard Magazine

Beyond the stethoscope

Following up last issue’s story, occupational physicians tell JACKIE BROWN-HAYSOM how they can add value to the management of health risks.

At the heart of occupational health there lies a paradox. On the one hand there are organisations who know they have to manage it, but struggle to work out how; on the other there are occupational physicians, specifically trained to know what ought to be done, who aren’t being consulted.

How did such an extraordinary situation come about? There are, it seems, a number of contributing factors.

For starters, because they are doctors, occupational physicians are often erroneously regarded as treatment providers, first and foremost. And because they are occupational physicians they’re not likely to be consulted unless a condition is indisputably work-related.

Then there’s the fact that there aren’t many of them, and their services don’t come cheap, which means most businesses opt to send sick or injured workers to local GPs. For whatever reason, these GPs seldom refer them on to occupational specialists.

Add to this that occupational physicians lack time and expertise for marketing, and it is little surprise that the message which could break the business boycott – that engaging a doctor who understands the workplace could, in the end, save money, and even lives – isn’t reaching the right people.

For the physicians it’s frustrating. Prevention is their primary role, and the area where they can make the biggest difference, but those who spoke to Safeguard say they get little opportunity to work in this area.

“What a lot of my colleagues are doing is what’s called tactical work,” says Hamilton-based Dr Mike Causer. “This is clinic work, seeing cases referred by an insurer – the ambulance at the bottom of the cliff.

“It’s useful, but the other side of what we can do, and what I’ve been involved with overseas, is strategic work.

“This involves health risk management – for a site, a company, or an industry. It’s helping identify hazards, making sure they’re mitigated, and then reviewing and improving the controls over time. Essentially health management’s no different from safety risk management – a process of continuous improvement.”

In an ideal world, he says, his time would be at least evenly divided between prevention and treatment, but in practice New Zealand occupational physicians can spend as little as two percent of their time in preventive work.

MANY SKILLS ON OFFER

Doctors may feel they’re missing out, but when you look at how things could be, it’s easy to argue that the real losers in this are the companies who could be using their expertise.

Occupational physicians have a wide and sometimes unexpected range of skills, reaching well beyond diagnosis and treatment.

Christchurch physician Dr Mary Obele puts it succinctly: “We do complex management of complex issues.”

In practice this can mean that, alongside treatment provision, they also liaise with all parties to develop rehabilitation and return to work programmes, investigate any work factors–including psychosocial ones – that may be contributing to existing problems or risking future harm, recommend and assess risk reduction measures, monitor health issues and workplace exposures, work with H&S teams to provide health and wellbeing education, and even give evidence on the company’s behalf in court, should the need arise.

But perhaps one of the most surprising things that occupational doctors are trained to do is communicate.

“We’re specifically trained to communicate around difficult issues with employers, clients and other practitioners,” says Nelson doctor Scott Newburn. “Facilitating communication between these parties, to get mutually beneficial solutions, is a huge part of our role. And when you consider that this includes things that both the employer and employee may be reluctant to discuss – like changing jobs, or even retiring – I think we’re a pretty helpful bunch.”

Sadly, however, there is still work to be done when it comes to successfully communicating the financial advantages of using their services.

“When employers think about occupational physicians they often just look at the bottom line and say ‘It’s really expensive,” Obele says. “They don’t realise there’ll be reductions in sick leave, overtime and the use of temps, fewer insurance claims, and less risk of legal and recruitment costs, not to mention all the management and administration time involved with injuries and illnesses.

“On top of that you get all the intangibles, like improved staff morale and productivity. If you calculate it all out, occupational physicians are good value for money, because there’s such a lot we can do.”

BEYOND MONITORING DECLINE

If cost savings alone are not enough to justify the use of doctors with occupational training, there are also the potential consequences of not using them.

At Auckland’s Penrose Clinic – a rare survivor of the industrial health clinics established by the government in the 1950s – Dr Thye Leow says GPs habitually fail to recognise – or even look for – occupational health issues. Leow, himself a GP with a post graduate diploma in industrial health, rather than an occupational medicine specialist, says the work pressure in general practice means there isn’t time to consider work-related factors.

“Worse, there are a lot of modern clinics where you see a different doctor every time you go.

“One guy came here because, after sending him to a GP clinic six times, his company had had enough. He’d seen six different doctors, and none of them could diagnose his diabetes!”

Similarly, the occupational health nurses who work with Dr David Beaumont have worrying stories about the way companies manage workplace health monitoring.

“The nurses themselves call what they do serial monitoring of decline,” Beaumont says. “If they get an abnormal result the employers refer it to a GP, who says “I’ll check it again next year.”

“When he does, and finds it’s worse, what does he say? “Check again next year.”

“Nurses often end up monitoring decline in things like lung function and hearing, while nothing is being done about the causes.”

In contrast, Beaumont says, occupational physicians regard health monitoring as a test for workplace controls, so abnormal results trigger risk assessment and environmental monitoring processes, to prevent further deterioration.

Causer agrees that health surveillance is not being used well.

“If you were a lawyer wanting to prosecute a company [the health monitoring records] would provide the perfect paper trail,” he says. “You’d be able to see that there was no supervision, no oversight, nothing had been done, and they’d continued doing the wrong thing until workers’ health suffered.”

HELPING RETURN TO WORK

The exclusion of physicians from health monitoring may also be contributing to a serious lack of occupational health data that has Obele worried.

“We don’t have hard data about work-related disease and death,” she says. “It’s just not reported.”

As an example, she says ACC gets few claims for occupational asthma, yet statistically, 20% of all asthma is expected to be occupational.

“It’s hard to know why more claims aren’t lodged – I don’t think it’s ACC’s fault – but it’s really sad that we’re not collecting the data, because a lot of these things are preventable, and they cause huge economic losses to the country.”

This isn’t the only area where the marginalisation of occupational physicians may be costing the country money, however.

Dr John Heydon, president of ANZSOM (the Australia and New Zealand Society of Occupational Medicine) says occupational physicians are skilled at getting those who have suffered serious illness or injury back into productive work, and without their services, some will struggle to re-enter employment.

“If people never get back to work it’s bad for all parties – the individual, the company and the national economy,” he says.

With an ageing workforce, chronic health issues such musculoskeletal injuries, cancers, cardiac problems – even mental health conditions – are becoming more prevalent, but Heydon says public health system support stops at the factory gate.

“There’s an assumption that at the end of the radiotherapy or whatever, you just step back into work, but it doesn’t happen like that.

“There are often complex problems associated with getting people back into work when they’ve been off for a long time, and I’m not sure industry fully appreciates what quality occupational health services can do for them in this situation.”

HOW TO GO MAINSTREAM?

With so much at stake, whose job is it to get occupational physicians into the mainstream of workplace health management?

The doctors themselves are equivocal. All agree that they need a much higher profile, but no one has a robust plan for achieving it. There is some talk of ANZSOM and AFOEM (the Australasian Faculty of Occupational and Environmental Medicine) having roles to play but, as small organisations run by volunteers, there’s little expectation they’ll make a real difference. The doctors also have a variety of ideas to promote themselves, but find work demands seriously limit what they can do.

As ANZSOM president, Heydon says the profession is trying to join forces with those from allied health fields to offer technical solutions to government, but the politics of funding are proving difficult.

“There’s a bit of an attitude of ‘prove your worth’ before you get funding, but you can’t prove your worth unless you get it.”

He’d like to talk to WorkSafe about what occupational physicians can do for the country, for industry and individuals.

“It would be good to foster a sort of triangular relationship between WorkSafe, industry and occupational health professionals, so they can see that we are a resource, and we can help them meet their targets.”

Others also believe WorkSafe has a role to play, at least in promoting the services of occupational physicians to potential clients, but Professor Bill Glass, a veteran of some 60 years in the profession, believes it’s ultimately up to doctors to find their own solution.

“Doctors need to ask themselves why they’re not being utilised,” he says. “We have to work out what we can offer as a group of specialists that will make industry value us.”

Causer believes physicians need to make an effort to engage with the H&S community, and with business, to create a better understanding of what they can do for them.

During a six-year stint in the UK he worked with a lot of large corporations, and says that by showing these companies how to implement good health strategies, it was possible to make a lot of difference to a lot of workers.

“You don’t need a full-time contract. You can go in to consult and troubleshoot, but they need to know when to use you.”

CULTURAL SHIFT REQUIRED

Newburn believes the profession’s multidisciplinary approach, which sees physicians working alongside ACC, occupational health nurses, and a variety of treatment providers, from surgeons and cardiologists to physiotherapists and psychologists, is helping build a community of interest that understands and values its skills.

He’s keen to see a shift into more preventive work, and believes that occupational medicine could be an effective way to improve the health of all working New Zealanders.

“It will take a cultural shift – but New Zealand is going through a cultural shift in health and safety at the moment,” he says. “The key thing is that health and safety legislation specifically says a person’s health is the employer’s responsibility, which means that the health of every person who steps out on a worksite is important.

“If we can get employers thinking like that, occupational health could play a pivotal role in preventive health.

“We could improve the health of the whole country through employment – but there’s a lot of work to be done, and there’s not a lot of us.”

JACKIE BROWN-HAYSOM

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