Demographics Change And The Future Of Occupational Medicine

There are regular reports on the changing demographics of the American worker (1). Similarly, news of the looming physician shortage also attracts considerable attention (2). Sandwiched between the work force and physicians are the specialty physicians that care for the work force. “Company doctors” at the time of Kaiser Permanente’s founding morphed into “industrial medicine” which as American industrial might began the process of moving offshore became “occupational medicine”. It’s a niche specialty, misunderstood even by many in healthcare whom lack exposure to preventive medicine in general. I have personally found the public confuses occupational medicine with occupational therapy. This is not at all unexpected when about one third of workplace injuries involve the upper extremity (3).

Decline

As a medical specialty though, occupational medicine is shrinking. As hospitals merge, employ more physicians than ever before, and fight with insurance companies less well-compensated care like worker’s compensation care takes a back seat. Residency training funding in occupational medicine is not tied to Medicare and has languished (4). The industrial medicine workforce has aged into retirement and with a replenishment rate of less than 100 newly minted physicians a year there is a double whammy of demographic decline. This further pushes the specialty to the margins. Aerospace medicine is another similar field with foreshadowing the same trends with a decreasing number of training programs. Much of the workforce of both occupational and aerospace medicine skews toward military and government positions where demand is still robust. In Pennsylvania to self-insure for worker’s compensation requires the retention of an occupational medicine physician or other worker safety focused specialties, no other medical specialty qualifies.

Differentiation

Beyond the regulatory requirements for the specialty, there is the need to employ the specialized skills that occupational medicine physicians are trained to perform. Occupational medicine physicians are residency trained in epidemiology which is the underpinning of any causation analysis. I have never met another physician outside of occupational medicine who has ever performed an independent medical examination in training. Many primary care practitioners have never reasoned fitness for duty beyond asking when their patient desires to go back to work as it is simply not part of their training. Causation, legal work and fitness for duty are where occupational medicine physicians truly shine. Whereas many specialties shy away from work comp as too-much-trouble where no-one-ever-gets-better, occupational medicine physicians partner with patients to get injured workers the best possible outcome. It’s often quoted that 20% of physicians care for 80% of work comp injuries; workers deserve better access to care.

Going Forward

Occupational medicine as it’s often truncated is actually “occupational and environmental medicine” (OEM)(5). Not only do OEM physicians train in understanding the medical aspects of work, we seek to also understand the environmental impact on human physiology. As total worker health and mental health interventions in the workplace evolve there will be a great demand for OEM physicians to provide those services, hopefully there will be enough.

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