Occupational medicine

Gordon Parker and James Mackie explain what is involved in this specialty and how to train for it

Mention "occupational medicine" to a medical student or to a doctor in the first few years of training, and you are likely to be met with a blank expression. Few students, preregistration house officers, or senior house officers will know anything about the specialty as occupational medicine no longer features as a distinct specialty in the undergraduate curriculum and there is currently only one senior house officer post in occupational medicine. Even when there was an occupational health component in the undergraduate curriculum, it was often based on a visit to a local factory or couple of lectures on industrial diseases that may not have captured the imagination.

Your exposure to "occupational health" in the early years of training may be confined to enquiries about your hepatitis B status and health questionnaires every time you change jobs. This level of contact with the specialty is hardly likely to fill you with enthusiasm for a career in occupational medicine.

Occupational medicine still isn't a high profile clinical specialty, but around 70 NHS consultants and 500 specialists are working in industry. Alongside the full time specialists are several hundred doctors, qualified to diploma level, who practice occupational medicine part time, usually in combination with general practice.

An occupational physician's nightmare- injuries caused by hedge trimmers

What exactly is occupational medicine?

Occupational medicine is essentially about the relation between health and work. This includes both the possible effects of work on health (occupational or "industrial" diseases) and the effects of someone's health on their capacity for work. Almost half the United Kingdom's population works, and in 1995-6, 1.3 million people reported ill health that they attributed to their work.¹ Lost working days amounted to 24.3 million, and 27 000 people had to give up their work because of ill health. Accidents in the workplace led to 1 million injuries--a big problem for affected individuals and for the economy.

What do occupational physicians do?

This will depend on the setting in which the doctor is employed: industry, NHS, armed services, or other organisations (including the Health and Safety Executive, research and insurance companies). It will also depend on whether the occupational physician is full time or part time, specialist or non-specialist. The rest of this article applies mainly to the specialist or career occupational physician, but part time occupational health practice can often add spice to a career in primary care, and we will deal with this in another article.

The most common clinical problems currently dealt with by occupational physicians are musculoskeletal (back pain and upper limb problems), psychological problems ("stress"--whether directly work related or not), skin problems, and respiratory problems (including occupational asthma). Assessing whether these are caused by work, exacerbated by work, or nothing to do with work can be challenging.

Clinical work

A typical day may include clinical work--assessing fitness for work of individuals who have health problems, looking at an employee's functional capacity for particular jobs and tasks, assessing the prognosis of an employee's ill health, and advising individuals and there employers accordingly. Developing rehabilitation and resettlement programmes for workers who have had illness or injury is a key role. There are obvious ethical constraints when an occupational physician gives advice to managers and employers, so communication and ethics are major components in the curriculum for specialist training. Giving impartial professional advice to employees and employers (and maintaining professional credibility) is a skill to be learned.

Epidemiology and legislation

But occupational physicians are not just involved with individual employees. We have to look at the workforce as a group, using epidemiological tools to investigate possible work related health problems. We have to have a real knowledge of the working environment--the chemical, biological, physical, and psychological hazards, and the actual risk of those hazards causing harm. Underpinning health and safety is a raft of legislation, so we become quite expert in health and safety law, and in the legal aspects of health and employment (disability discrimination, unfair dismissal, etc).

So, alongside the clinical work we investigate the environment, prepare policies to protect the health of employees, undertake research into specific hazards or clusters of "cases," advise managers and others on health issues, and organise and sometimes deliver training on a variety of topics from first aid to manual handling. We do all these things as part of a team. We usually work with trained occupational health nurses, occupational hygienists (who assess and measure environmental hazards), safety advisers, and other technical specialists.

Occupational medicine is rather different from most clinical specialties and offers great scope for extending your skills into research, medicolegal issues, safety and risk management, and so on.

The future of occupational medicine

This is an exciting time to be in occupational medicine, as awareness of the importance of occupational health is growing at government level, and several national initiatives require the input of occupational physicians. In the past three years, the government has published documents setting out a national strategy for reducing ill health in both workers and the public, to help people who have been ill return to work, and to improve work opportunities for people who are currently not employed because of ill health or disability.^{2 3} Musculoskeletal problems--particularly back pain--have been targeted, with the Faculty of Occupational Medicine (FOM) issuing evidence based guidance on the clinical management of back pain, with the aim of reducing sickness absence and improving rehabilitation.⁴

As part of this strategy, the government also aims to improve access to occupational health services, particularly for workers in small or medium sized firms. The NHS is playing a major part in this, with NHS occupational health departments offering their expertise to local industry in the NHS Plus initiative. Occupational health advice to the NHS workforce (including general practitioners and their staff) is being expanded as part of the "Improving Working Lives" initiatives.⁵ There is no doubt that more specialist occupational physicians are needed to make these plans work.

What does specialist training involve?

Specialist training is possible in industry and the NHS (or even a mixture of the two), in organisations providing consultancy services to industry, and in the armed services. At present, there is only one senior house officer post in the specialty (in the West Midlands), but we are exploring the possibility of establishing more posts with the reform of the SHO grade.

Entry to specialist training is therefore at specialist registrar level, and the minimum entry requirements are three years post-qualification experience in a variety of medical specialties (at least two years in supervised senior house officer posts). Possession of the membership of the Royal College of Physicians or the Royal College of General Practitioners is desirable. Experience in general medicine or general practice is particularly useful, as is training in rheumatology, dermatology, accident and emergency medicine, and psychiatry. It is not uncommon for applicants to enter training after having completed general practice training, or from other medical specialist registrar posts, or switch to occupational medicine after a couple of years in primary care.

Training takes a minimum of four years and covers a variety of broad headings. These broad headings cover a wide variety of topics. For example, what are the statutory health surveillance requirements for radiation workers? What are the fitness standards for firefighters? What diseases or disabilities might bar someone from working offshore (and can they be overcome)? What
occupational disorders are associated with exposure to welding fumes, flour dust, or vibrating hand tools? How would you write a drug and alcohol policy for a company? How would you investigate a cluster of cases of sore throat in an office block?

Occupational physicians acquire much "non-medical" knowledge in their work. Doctors in the food industry can tell you in great detail how bread is baked or how prawns are extracted from their shells. Doctors in engineering will talk knowledgeably about raw materials and processes, and doctors in the offshore industry can tell you how oil and gas are extracted from the seabed. All these things may seem irrelevant to clinical practice, but they are essential if we are to understand what tasks our employees actually do and what hazards they are exposed to.

To obtain membership of the Faculty of Occupational Medicine (MFOM) and a certificate of completion of specialist training (CCST) in occupational medicine, specialist registrars are required to: (1) complete a minimum of four years in an approved training post; (2) pass the AFOM (Associate of the Faculty) examination based on the curriculum above at about the mid point of training; and (3) undertake a piece of original research or investigation leading to a dissertation. Several academic centres offer day release or distance learning courses aimed at the AFOM syllabus, some with the option of going on to obtain an MSc. Employers will often help with the funding of such courses and, in the private sector, help may also be available for additional costs such as examination fees.

Other benefits of working in occupational medicine

Apart from the development of new skills, including research and management, there are often opportunities to travel (particularly if you work for a multinational organisation) and as most jobs are done in "office hours," you are unlikely ever to have to get out of bed at 3 am.

There are also opportunities to work in many different working environments and experience many different management cultures. Another positive benefit is the scope to take on new jobs and challenges right up to retirement.

Openings exist for part time work and for working in a variety of different posts as part of a "portfolio" career.

Pay

National pay scales apply to specialist registrars in the NHS, although there are usually no supplements for on call work or intensity payments. Salary protection applies to doctors changing careers from other NHS jobs. Trainees in industry are employed on terms and conditions determined by the employing organisation. These vary but are always at least comparable with NHS scales.

NHS consultants are paid according to national guidelines, but a current shortage of qualified specialists makes it possible to negotiate the starting point on the scale. Salaries for specialists in industry are privately negotiated and will reflect the seniority of the position, experience, and the economic climate. Suggested levels are published by the BMA and are roughly comparable to NHS consultant posts. Posts in industry may attract additional benefits such as company cars, private medical insurance, and share options. Pension benefits are not always as good as in the public sector.

Gordon Parker, group medical adviser, Ranks Hovis McDougall; training dean, Faculty of Occupational Medicine, London
Email: Training.Dean@facoccmed.ac.uk

James Mackie, specialist registrar , Previa UK, RedditchWorcestershire
Email: james.mackie@previauk.com


studentBMJ 2002;10:303-352 September ISSN 0966-6494

1. Health and Safety Executive. The costs to Britain of workplace accidents and work related ill health. London: HSE Books, 1999.
2. Occupational Health Advisory Committee. Improving access to occupational health support. London: HSE Books, 2000.
3. Health and Safety Executive. Securing health together--an occupational health strategy for England, Scotland and Wales. London: HSE Books, 2000.
4. Faculty of Occupational Medicine. Occupational health guidelines for the management of low back pain at work. London: FOM, 2000.
5. Department of Health. The NHS plan. A plan for investment. A plan for reform. London: Stationery Office, 2000.