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Keeping Workers On the Job

OCCUPATIONAL MEDICINE: A LITTLE-KNOWN SPECIALTY OFFERING A WIDE RANGE OF CAREER OPTIONS

The New Physician July-August 2004
Dr. Phillip Franklin is helping to redesign the way we build cars in America. It’s not something the University of Colorado School of Medicine trained him for back in the early 1980s, but to be sure, he’s now standing on the assembly line floor in the General Motors (GM) plant talking about the most ergonomic way for an autoworker to build a car.


The Wilmington, Delaware, factory, which until now has built cars for GM’s Saturn division, is about to begin rolling out the Pontiac Solstice, a zippy little two-seat convertible slated to hit car lots in the fall of 2005. But first, plant engineers have to create the assembly line. And as the plant’s medical director, Franklin is a sort of go-between for the workers and those who design how they do their jobs. “You’ve got to listen to the patient,” he says. From what he learns about their complaints, he can tell the line engineers, “You’ve got a bad bend and twist here; you’ve got a bad bend and twist there. Why do that to people?”


And so they won’t. Thanks in part to Franklin’s constant study of how plant jobs cause injuries and why, Solstice’s assembly line is expected to employ new techniques in car-building technology that should reduce workers’ injuries. It makes one wonder what might have been different in car manufacturing if Henry Ford had collaborated with an occupational medicine physician 100 years ago.


REPETITIVE STRESS INJURIES AND MORE


“I shadowed an occupational med doc.… All I saw that day was a whole bunch of physicals and disgruntled truck drivers who couldn’t get their licenses renewed because their HbA1c was too high,” a medical student posted recently on an online bulletin board.


“A lot of people think that’s what occupational medicine is—doc-in-a-box sort of thing,” Franklin says. “But there’s so much more.”
For instance, the workshop offerings at a recent American College of Occupational and Environmental Medicine (ACOEM) conference included: “Depression in the Workplace,” “Waterborne Disease,” “New Eye and Face Protection Standards,” “Agricultural Chemicals,” “Helping Workers and Their Families Quit Smoking” and “Molecular Epidemiology.”


“What I like about occupational medicine is that it’s a really wide-open field. You’re really taking care of patients,” Franklin says. As medical director, he oversees a team of physicians, nurses and EMTs in the on-site, inpatient medical clinic, and he says he loves caring for patients. But with an M.P.H. under his belt, he also enjoys the epidemiology.


When he arrived at the plant in 1999, the facility was plagued with GM’s second-worst accident rate. “The good thing was I couldn’t make it any worse.” But, putting his epidemiology skills to work, he pieced together what was causing the injuries and determined ways the plant could curb them. One of the solutions was to evaluate the plant’s 2,500 workers on whether they were physically suited to their jobs; if they weren’t, they were moved. “We’ve put people in the right job for them so they’re not getting hurt,” he says.


When employees do get injured, Franklin keeps track of their locations at the time of their injuries, what protective gear they were—or were not—wearing and other details in a handheld computer that maps out the information. He shares the graphics with the plant’s area supervisors along with instructions on how to prevent future accidents.


Through these efforts, Franklin and his team reduced the plant’s injury rate by 90 percent, saving GM more than $1 million in health-care costs. “I like to touch people. I want to improve their health—but I’ve moved beyond just that,” he says, adding he enjoys caring for a patient population in which most are in the prime of their working lives.


“What you’re doing in medicine is treating a disease, but in occupational medicine, you’re actually getting to work with a healthy work force,” says Dr. Pamela Hymel, a former medical director for Hughes Electronics in El Segundo, California, who recently finished her term as ACOEM’s treasurer.


And Franklin says he sees even more opportunities for the occupational medicine physician at GM: The company is considering expanding its services to also provide primary care for workers and their families and better educate them from a health promotion standpoint. He’s seen workers struggle with suicide, homicide and drug dependencies—outside issues that affect workplace health. The company can help, he says. “We have a captured population. We should tap into that.”


Hymel says population health management through a benefits program is relatively new to the specialty. As Hughes Electronics’ medical director, she crafted prevention policies for 52,000 employees. “One of the most challenging things I did…was working on the health and wellness of our employees and working with our benefits people.… We need to look at a patient from a variety of perspectives and teach them how to stay healthy because there are some benefits to going to work.”


CLINICAL CARE WITH SOME COMPLICATIONS


Of course, occupational medicine can simply be clinical in practice as well. About 80 percent of Dr. Steven Hendler’s Kansas City-based physical medicine practice involves treating on-the-job injuries, despite the fact he is not board certified in occupational medicine (see “The Road to Occ Med,” below). Hendler did a residency in physical medicine and rehabilitation, but “over the years my practice has evolved. I’m doing this type of work in a progressively increasing amount.”


Employers refer most of Hendler’s patients to him, and the vast majority suffers from musculoskeletal, back, arm, neck, and compressed nerve injuries. He sees more manual labor injuries—mostly because of his Midwest location—but there are desk-bound workers who have wrenched their backs moving a box of copier paper.


This brand of clinical practice has its challenges, though. A lot of psychosocial issues become intertwined with their physical injuries, he says, “and so you need to have a very good understanding of those issues.” For example, he cites a study that found patients with active workers’ compensation claims do not respond to treatment as well as those who have settled their claims. It all has to do with how you see your employer, he says. “In a good economy, and you sit at a desk and get a little arm pain, you’re going to put up with that because you’re raking in money. In a down economy, you’re not.”


And if you think patients check those issues at the exam room door, you’re wrong. “You have to be a little steely-eyed to do this,” he says.
His conscience raises a red flag whenever a patient says his boss made him come in for an exam because he believes the employee is faking the injury. The same is true whenever a referral comes with an employer complaint about the worker simply wanting a vacation. “That’s a situation where I can see the patient is not going to get better,” he says. Complications also arise when employers use workers’ comp cases to resolve human resources issues and look to Hendler for an excuse to fire a problem employee.


“It’s almost like doing battlefield care…, and you’re in the middle of it because you’re trying to get the patient better, and that’s a challenge, and sometimes it’s an annoying challenge.


“In traditional health care,” he says, “you’ve got the patient, the provider and health insurance. In occupational medicine, you’ve got the patient, the provider, health insurance and the employer.… And the other is the judge.”
That’s right. Some occupational medicine physicians spend a lot of time as experts in court cases. Hendler says he gets deposed in workers’ comp disputes between two and 10 times a month. And about twice a week employers submit surveillance tapes for him to review, in an attempt to prove an employee is faking an injury. “That’s the funny ones—where the guy says he can’t lift anything, and they have videotape of him lifting boxes, aquariums….”


These issues turn some patients nasty and even threatening, Hendler says. They may be trying to get the physician to refuse treatment, so their exasperated employer will allow them to see any physician, potentially someone who is unfamiliar with their background. “In those cases we hold on a lot longer,” he says. Some of his patients have already been through several physicians before him.


Franklin says his work can get complicated as well, particularly when he feels trapped between union disputes and management. In those situations, maintaining a neutral position and developing strong working relationships with union leaders is key. “Sometimes my job is to get management and unions to understand what they can and can’t do,” he says. “My job is to be the collective conscience of the plant.… As a doctor, you have certain ethical and moral [standards] you have to adhere to.… I go to workers’ comp. I testify against people. I just don’t make it personal.” He says if he did, he would lose perspective of the causes and effects of problems and how to resolve them.


But determining the root administrative causes of injuries isn’t usually Hendler’s focus, so he admits it’s not always the ideal clinical experience. In fact, when a premed neighbor asked to shadow him for a day, he told her it wasn’t such a good idea.


Still, he tries to look at the challenges optimistically. “It’s like panning for gold in that when you have a success, when someone comes in who’s failed everything…and you get them to a place where they are better than when they came to you, that’s rewarding. I mean, yeah, there are days where every patient is a problem, and I think, ‘Oh, I’ve got to get out of here. I’ve got to retire, be a garbage man, whatever….’ [But] I enjoy the process of figuring out what is going on, even if I can’t make it better. And frankly, as a business owner who has to pay workers’ comp premiums, I do want to make sure people aren’t taking advantage of the system.”


IN THE FIELD


Complications aside, though, occupational medicine’s lifestyle can be very attractive. “I won’t be dishonest. It is financially rewarding,” Hendler says. What other specialty can boast a 100 percent coverage rate among its patients? Everything Hendler does is billable, either to workers’ compensation or, in the case of his depositions, to the lawyers calling him to testify.


Franklin agrees the specialty offers a better lifestyle than others. He says he makes “less money than a surgeon, but I also don’t have the issues they have.” It’s a 9-to-5 job for the most part, although every now and then he has to deal with a problem on the night shift. But GM understands he has a life outside of medicine, he says. “You get treated more like a real person.”


A 2002 ACOEM survey found the average total compensation—including salary, bonuses and consulting fees—for an occupational medicine physician is $188,000, and Hymel says it can range from $150,000 to $200,000. This depends on your training and practice—in which the options are broad.


Of the roughly 5,000 occupational medicine physicians in the country, 18 percent work in an administrative capacity, similar to Hymel and Franklin. Another 65 percent are clinicians like Hendler. Others consult with companies and the federal government—about 20 percent of ACOEM members are government employees working with state and federal policies—and small percentages teach and do research.


The opportunities continue. Hymel says the military employs one of the largest groups of occupational medicine physicians—their expertise in chemical exposure and toxicology is invaluable. Franklin was recently offered a job with the National Aeronautics and Space Administration (NASA). While the tug of outer space is strong, he says he can’t uproot his family. He admits, though, that working for NASA would be one of the coolest jobs—still, there seem to be plenty more here on Earth.
Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.