Requirements for occupational medicine training in Europe: a Delphi study.

Abstract

To identify the common core competencies required for occupational physicians in Europe.
A modified Delphi survey was conducted among members of the European Association of Schools of Occupational Medicine (EASOM), the Occupational Medicine Section of the Union of European Medical Specialities (UEMS), and of the European Network of Societies of Occupational Physicians (ENSOP). An initial questionnaire based on the training syllabus of the United Kingdom Faculty of Occupational Medicine was circulated and respondents were asked to rate the importance of each item. The results were discussed at a conference on the subject of competencies. A further questionnaire was developed and circulated which asked respondents to rank items within each section.
There was a 74% response in the first round and an 80% response in the second. Respondents' ratings from most important to least important were; occupational hazards to health, research methods, health promotion, occupational health law and ethics, communications, assessment of disability, environmental medicine, and management. In the second round, among those topics ranked most highly were; hazards to health and the illnesses which they cause, control of risks, and diagnoses of work related ill health. Topics such as principles of occupational safety and selection of personal protection equipment were of least importance. Although the assessment of fitness was regarded as important, monitoring and advising on sickness absence were not highly rated. Management competency was regarded as of low importance.
This survey identified that respondents had traditional disease focused views of the competencies required of occupational physicians and that competencies were lagging behind the evolving definition of occupational health.

Full text

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Requirements for occupational medicine training
in Europe: a Delphi study
E B Macdonald, K A Ritchie, K J Murray, W H Gilmour
Abstract
Objectives—To identify the common core
competencies required for occupational
physicians in Europe.
Method—A modified Delphi survey was
conducted among members of the Euro-
pean Association of Schools of Occupa-
tionalMedicine
Occupational Medicine Section of the
Union of European Medical Specialities
(UEMS), and of the European Network of
Societies ofOccupational
(ENSOP). An initial questionnaire based
on the training syllabus of the United
Kingdom Faculty of Occupational Medi-
cine was circulated and respondents were
asked to rate the importance of each item.
The results were discussed at a conference
on the subject of competencies. A further
questionnaire was developed and circu-
lated which asked respondents to rank
items within each section.
Results—There was a 74% response in the
first round and an 80% response in the
second. Respondents’ ratings from most
important to least important were; occu-
pational hazardsto
methods, health promotion, occupational
health law and ethics, communications,
assessment of disability, environmental
medicine,and management.In the second
round, among those topics ranked most
highly were; hazards to health and the ill-
nesses which they cause, control of risks,
and diagnoses of work related ill health.
Topics such as principles of occupational
safety and selection of personal protection
equipment were of least importance. Al-
though the assessment of fitness was
regarded as important, monitoring and
advising on sickness absence were not
highly rated. Management competency
was regarded as of low importance.
Conclusion—This survey identified that
respondents had traditional disease fo-
cused views of the competencies required
of occupational physicians and that com-
petencies were lagging behind the evolving
definition of occupational health.
(Occup Environ Med 2000;57:98–105)
(EASOM), the
Physicians
health,research
Keywords: competencies; Delphi study; occupational
medicine training
One of the first to describe the competencies
required of occupational physicians was Ber-
nadino Ramazzini when he emphasised the
importance of the occupational history: “and
to the questions recommended by Hippocra-
tes, he should ask one more ‘what occupation
does he follow?’”
principles of risk assessment when he wrote
“the physician should not think it unbecoming
to visit the lowliest workshops and study the
mysteries of the mechanic arts.”
The International
(ILO) and the World Health Organisation
(WHO) have had a common definition of
occupational health since the formation of the
ILO/WHO Joint Committee on Occupational
Health in 1950. This was revised in 19852to
reflect the increasing emphasis on occupational
health promotion presented in the WHO
Global strategy for health for all by the year 2000.
The definition was further broadened in May
1996 at the 49th World Health Assembly to the
following: “the overall promotion of health and
workability for all employees”.
These revisions have resulted in a changing
need for occupational health to encompass
health promotion as well as health protection,
an active improvement of the working environ-
ment, and the development of work organis-
ation and culture to support health and safety
at work. In turn this has led to changing
requirements in the competencies which occu-
pational physicians need to have. Additional
influences are also developments within the
commercial world, with industry increasingly
becoming international and the widespread
application of quality management principles
to all industrial activities.
Across the European Union fundamental
principles of harmonisation and free move-
ment of labour and capital have led to a
common basis for health and safety legislation
and also the training and mutual recognition of
medical specialists. Reference to competent
people also occurs within the legislation of
individual countries and is often used within
United Kingdom legislation. However, legisla-
tive bodies, while using the word competent,
have not defined what is meant by competent
when referring to trained occupational physi-
cians.
The curricula of specialist training within
countries of the European Union have thus
been underpinned by general principles, the
ILO, WHO agreements, and more recently, by
EU legislation. However, within Europe it has
been clear that the emphasis of training, and
indeed the roles of occupational physicians,
have varied considerably depending on histori-
cal practice and local legislation. For example,
some countries do not have trained occupa-
tional health nurses,whereas in other countries
this related discipline is highly developed.
1He also established the
LabourOrganisation
Occup Environ Med 2000;57:98–105 98
Department of Public
Health, University of
Glasgow, 1 Lilybank
Gardens, Glasgow G12
8RZ, Scotland, UK
E B Macdonald
K A Ritchie
K J Murray
W H Gilmour
Correspondence to:
Dr E B Macdonald,
Department of Public
Health, University of
Glasgow, 1 Lilybank
Gardens, Glasgow G12 8RZ,
Scotland, UK
Accepted 16 September 1999
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In response to these changes three European
networks of occupational physicians have
developed. The first of these was the European
Association of Schools of Occupational Medi-
cine (EASOM), followed by the Occupational
Medicine Section of the Union of European
Medical Specialties (UEMS) and the Euro-
pean Network of Societies of Occupational
Physicians (ENSOP). The UEMS has pro-
duced European Charters on the training of
medical specialists and working groups are
active in the production of European standards
and qualifications and have access to the politi-
cal framework in Europe through the Comité
Permanent of the European Union. The
EASOM and ENSOP are professional net-
works developed in response to professional
initiatives and have no formal mandates.
Within all these organisations discussions on
the required competencies and activities of
occupational physicians has been a major topic.
In early 1997 the Board of the EASOM rec-
ommended that the common core competen-
cies required of occupational medicine special-
ists across Europe should be drawn up. It was
decided therefore that a survey would be
conducted among the members of EASOM,
UEMS, and ENSOP. Membership of EASOM
is open to institutions which provide post-
graduate training resulting in a recognised spe-
cialist qualification in occupational medicine.
The UEMS occupational medicine section
comprises two people from each member state
elected through the professional association—
for example, the British Medical Association in
the United Kingdom. One representative must
be an academic and the other a practitioner.
The ENSOP is comprised of two nominated
members from each of the national societies of
occupational medicine within the European
Union. Opinions could be then obtained from
this survey population of representatives of
academics and practitioners in occupational
medicine. A form of the Delphi process was
used in an attempt to derive consensus of these
opinions.
Method
The survey took the form of a Delphi study
with a questionnaire being developed, circu-
lated, and modified and then the modified ver-
sion redistributed to the participants. The Del-
phi technique has been used in several diVerent
ways relating to the problem being approached
and group responding.3 4It has been success-
fully used in the past to collate the opinions of
occupational physicians.5–7In the study re-
ported here an existing list of competencies
required of specialists in occupational medi-
cine was circulated as a questionnaire. This list
of subjects was derived from the United King-
dom Faculty of Occupational Medicine train-
ing regulations which describes eight basic
competencies.8These competencies are further
divided into three areas—namely, knowledge,
experience, and competence. For the purposes
of this study, these terms have been defined in
table 1.
The questionnaire was distributed to all
members of EASOM, UEMS, and ENSOP
included in mailing lists available at the time.
The mailing lists identified 34 EASOM, 23
UEMS, and 32 ENSOP representatives. Alto-
gether 89 questionnaires were distributed in
the initial circulation and respondents were
asked to indicate the relative importance of the
items and to add to the lists where appropriate.
Returned questionnaires were analysed and
preliminary results were communicated at a
conference exploring the topic area and held in
Glasgow in April 1997.9During this confer-
ence all delegates were given copies of the first
questionnaire. This conference also explored
and compared the description of competencies
of national standard setting bodies throughout
Europe, the United States, and Australasia.
A second questionnaire was then produced
including items added by first round respond-
ents and conference delegates. No items were
removed from the lists but all new topics
suggested by respondents were included. The
resulting questionnaire retained the same
structure of 24 sections with a total of 160
items. This second questionnaire was then cir-
culated again to 87 members of the organisa-
tions involved for whom current addresses
could be obtained.In this instance respondents
were asked to place each of the items in rank
order within the 24 sections. The item consid-
ered most important was given a rank of 1,next
most important 2 and so on. It was not permit-
ted to give 2 items in a subsection the same
score. Additional items were not invited in this
round although a section for remarks was
included.
Table 1Definitions
Knowledge
Experience
Competence
Specific information about a subject
Direct personal participation or observation
The condition of being capable; ability; the state of being legally competent or
qualified
Table 2Distribution of responses by country
Country
Respondents
(n) Country
Respondents
(n)
Austria
Belgium
Bulgaria
Czech Republic
Denmark
Finland
France
Germany
The Netherlands
Hungary
Ireland
Italy
2
3
2
6
2
1
2
Latvia
Lithuania
Norway
Portugal
Russia
Slovak Republic
Spain
Sweden
Switzerland
Turkey
United Kingdom
Total
1
2
4
4
1
3
1
3
2
1
4
10
3
1
2
5 65
Table 3 Mean scores of topic areas
Mean scores
KnowledgeExperience Competence
Occupational hazards to health
Research methods
Health promotion
Occupational health law and ethics
Communications
Assessment of disability
Environmental medicine
Management
4.4
4.3
4.1
4.0
4.0
3.7
3.4
3.3
4.2
4.0
3.6
4.0
4.0
3.6
3.5
3.3
4.5
4.0
3.6
4.2
4.2
3.9
3.5
3.6
Requirements for occupational medicine training in Europe
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Results
ROUND 1
Of 88 questionnaires sent out, 65 responses
(74% response rate) were received within the
given time limit. These eligible responses
represented 23 countries (table 2). Question-
naires were not received in time from Poland
and there were no questionnaires returned
from Croatia, Greece, Luxembourg, Romania,
or Ukraine.
The number varied from country to country
depending on the nationality of the various
committee members, and subsequent local
distribution of the questionnaire led to addi-
tional responses from some countries—for
example, 10 from Germany.
Respondents were asked to give each item on
the list a separate score from 0 to 5 relating to
the importance of the subject. A score of 0
indicated that the item was not necessary, 1 it
was of minimal importance, and 5 it was most
important or essential. Results were entered
into a database package on a personal compu-
ter and analysed with the statistical package for
Table 4 Results of Wilcoxon signed ranks tests for knowledge subsection with mean scores of subject areas indicated
Occupational
hazards to
health
Research
methods
Health
promotion
Occupational
health law and
ethicsCommunications
Assessment of
disability
Environmental
medicineManagement
4.354.30
NS
4.14
*
3.96
***
3.95
***
3.73
***
3.39
***
3.30
***Occupational hazards to health
4.35
Research methods
4.30
Health promotion
4.14
Occupational health law and ethics
3.96
Communications
3.95
Assessment of disability
3.73
Environmental medicine
3.39
Management
3.30
NS ****** *** ******
***** ******
NS* ******
**** ***
* ***
NS
*p<0.05; **p<0.01; ***p<0.001 row item higher v column.
Table 5Results of Wilcoxon signed ranks tests for experience subsection with mean scores of subject areas indicated
Occupational
hazards to
health Communications
Research
methods
Occupational
health law and
ethics
Assessment of
disability
Health
promotion
Environmental
medicine Management
4.18 4.00
NS
4.00
NS
3.95
NS
3.63
***
3.60
***
3.50
***
3.25
*** Occupational hazards to health
4.18
Communications
4.00
Research methods
4.00
Occupational health law and ethics
3.95
Assessment of disability
3.63
Health promotion
3.60
Environmental medicine
3.50
Management
3.25
NSNS *** ***** ***
NS*** ** ***
** NS**NS
NSNS ***
NS **
*
*p<0.05; **p<0.01; ***p<0.001 row item higher v column.
Table 6Results of Wilcoxon signed ranks tests for competence subsection with mean scores of subject areas indicated
Occupational
hazards to
health
Occupational
health law and
ethicsCommunications
Research
methods
Assessment of
disabilityManagement
Health
promotion
Environmental
medicine
4.464.23
*
4.18
***
4.01
***
3.87
***
3.64
***
3.58
***
3.54
*** Occupational hazards to health
4.46
Occupational health law and ethics
4.23
Communications
4.18
Research methods
4.01
Assessment of disability
3.87
Management
3.64
Health promotion
3.58
EnvironmentalmMedicine
3.54
NS*** *** ******
**** *** ******
NS*** ****
*NS*
NSNS
NS
*p<0.05; **p<0.01; ***p<0.001 row item higher v column.
100
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the social sciences (SPSS). The knowledge,
experience and competence subsections were
treated separately. For each item in each of
these subsections, the scores were averaged for
all respondents and these are shown in table 3.
Results of analyses carried out to find if there
was any variation in responses between people
from diVerent regions—for example, Eastern
European respondents compared with those
from Mediterranean countries—showed this to
Table 7Standardised rankings
Occupational hazards to health:
Section 1A, knowledge:
Hazards to health in the workplace and the illnesses which they cause
Evaluating and controlling risk from hazards
Principles of toxicology, occupational hygiene, and ergonomics
Clinical features and investigation of occupational disease
Sources of information in occupational health hazards
Principles of health surveillance
Occupational health standards
Biological monitoring
Principles of occupational safety
Emergency treatment of injury at work
Section 1B, experience:
Assess and advise on range of working environments
Surveillance of workers at risk of occupational injury and disease
DiVerential diagnosis of work related ill health
Liaison with other specialists on workplace assessment
Management of workers developing work related disease or injury
Use of basic occupational hygiene equipment
Experience in general clinical toxicology
Supervise health and safety training
Use of ILO classification of radiographs
Section 1C, competence:
Undertake workplace assessments and advise on control measures
Diagnose work related ill health
Take a clinical history and examination proficiently
Organise appropriate investigations for diagnosis of occupational disease
Recognise need for specialist assessment of environment
Organise health surveillance for workers exposed to occupational hazards
Advise on provision of first aid facilities
Select appropriate personal protective equipment
Advise on the use of equipment and the planning of working environment
Advise on the introduction of new working systems and techniques
Assessment of disability and fitness for work:
Section 2A, knowledge:
Principles of assessing fitness for work
Statutory requirements for fitness for specific jobs
Methods of rehabilitation and redeployment at work
Factors eVecting absence attributed to sickness
Assessment of fitness for work of older workers
Application of the stress or strain concept to disabled employees
Principles of ill health retirement
Disablement benefits
Section 2B, experience:
Clinical assessment of disability and fitness for work, both preplacement and after work related illness or injury
Assessment of impairment, disability, and handicap in relation to work
Clinical management in rehabilitation of disabled workers
Application of ergonomics to rehabilitation
Counsel employees regarding sickness absence
Management of workers with alcohol or drug problems
Monitoring sickness absence
Supervise training
Section 2C, competence:
Advise on impairment, disability, and handicap in relation to work
Advise on fitness for work in liaison with other professionals where appropriate
Advise on rehabilitation and redeployment
Advise managers, insurers, and employers on ill health retirement
Advise on sickness absence
Communications:
Section 3A, knowledge:
Organisation of occupational health services and role of statutory authorities
Ethical guidelines for communications with doctors, managers, and others
Role and organisation of other occupational health professionals
Organisation of other health services
Principles, techniques, and resources in communication
Organisation of occupational health services in other European countries
Section 3B, experience:
Preparation of written reports
Communications with other professionals about management of people
Oral presentations with audiovisual aids
Teamwork
Counselling
Participation in committees
Negotiating,influencing,and conflict resolution
Section 3C, competence:
Communicate with people of diVering backgrounds and technical understanding
Organise and write reports
Make clear oral presentations with use of audiovisual aids
Read, write, and converse proficiently
Apply legislative and ethical requirements for confidentiality in communicating with other professionals about
people
Participate eVectively as a member of a committee
1.6
4.2
4.5
4.8
5.0
5.6
6.5
6.8
7.5
7.6
3.5
3.6
4.1
4.3
4.8
6.5
6.9
7.1
8.5
3.2
3.6
3.7
4.3
4.6
4.8
7.1
7.5
7.5
7.7
2.8
3.9
4.6
5.1
6.5
6.8
7.1
7.7
2.7
3.1
5.2
5.5
6.3
6.5
7.4
7.7
4.1
4.2
5.5
7.7
8.0
3.2
5.1
5.6
6.0
6.3
8.2
3.7
4.4
5.0
5.7
6.7
6.9
6.9
4.2
5.2
5.4
5.5
6.0
8.3
Items in italics were not in the first questionnaire.
Requirements for occupational medicine training in Europe
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be small in responses. Notable diVerences were
that respondents from Belgium and Holland
tended to rate the topics within the sections on
assessment and disability more highly than
respondents of other nationalities. Also, re-
spondents from the United Kingdom and
Ireland and the Nordic countries placed less
importance on health promotion topics than
the other national groupings. (Further infor-
mation about these diVerences in the knowl-
edge section is available from the authors.)
Health promotion and management are recog-
nised by WHO as increasingly important
within the discipline; issues surrounding dis-
ability are of particular importance in some
European countries; occupational hazards to
health encompasses the traditional historical
areas of occupational health. There was greater
variation of mean scores for occupational haz-
ards to health than the other subject areas.
Table 7Standardised rankings—continued
Research methods:
Section 4A, knowledge:
Sources of scientific information
Principles of epidemiology and medical statistics
Ethical considerations in research
Principles of social and qualitative research
Section 4B, experience:
Conduct a formal scientific investigation
Carry out a literature search and prepare a report
Section 4C, competence:
Carry out a literature search
Convert a problem into a researchable question
Interpret scientific data in journals and from own research
Plan simple surveys
Recognise limits of competence and liase with statisticians or other experts when appropriate
Recognise and initiate the investigation of disease clusters in the work force
Report on an investigation orally and in writing
Carry out simple statistical manipulations to summarise data
Analyse routinely collected data including sickness absence and accident data
Use a computer for the storage and analysis of data
Management:
Section 5A, knowledge:
Principles and practice of management
Techniques for needs assessments and marketing of occupational health services
How to manage a budget
Industrial relations
Management structures in diVerent organisations
Principles of audit
Analysis of organisational behaviour
Designing a training course
Section 5B, experience:
Personal responsibility for the management of a department or some aspect of a department of occupational
health
Involvement with all elements of industrial organisation
Experience in at least two organisations or businesses with diVerent structures and styles of management
Collection and use of information in the management of health and safety at work
Participation in audit
Managing a budget
Selection, appointment, supervision, and appraisal of staV
Involvement in providing training
Attendance at a management training course
Section 5C, competence:
Identify the occupational health needs of an organisation
Define the goals and objectives of an occupational health service
Define the roles of staV in providing an occupational health service and formulate job descriptions
Manage an occupational health department
Evaluate the quality of an occupational health service and carry out clinical audit
Negotiate and manage a budget
Team building and teamwork
Organise record keeping with computers if appropriate
Select, appoint, supervise and appraise staV performance
Market occupational health services
Negotiating and influencing skills
Design a training programme
Occupational health law and ethics:
Section 6A, knowledge:
Acts, regulations, codes of practice and guidance governing occupational health including the reporting of
occupational injury and disease
The legislative framework of occupational health in the relevant country and European Community
The interaction between the law and ethics in occupational health practice
Industrial compensation systems
The roles of the medical, professional, and expert witness
Organisation of social and insurance services
Employment law
Social compensation legislation
Environmental health law
Procedures in litigation
Section 6B, experience:
Advising on, supporting, and monitoring the implementation of occupational health and safety legislation
Application of occupational health law and ethics to the individual case
Advising on,supporting,and monitoring the implementation of environmental law
Evaluation of compliance with new legislation
Section 6C, competence:
Advise managers of their legal obligations under health and safety law
Advise managers on the implementation of health and safety and environmental law
Advise workers and workers’representatives of their legal obligations
4.4
4.9
7.2
8.1
7.0
7.8
3.9
4.0
4.6
4.9
5.3
5.7
6.2
6.4
6.4
6.8
2.7
4.8
5.0
5.1
6.1
6.3
7.0
7.5
3.2
3.7
4.9
5.1
5.8
6.0
6.2
7.0
7.3
2.2
2.5
3.8
3.8
5.4
5.7
6.1
6.5
6.6
6.7
7.3
7.4
2.6
3.0
3.7
5.4
5.7
6.2
6.6
6.7
6.8
7.3
4.2
4.6
7.8
8.0
4.9
7.2
7.6
Items in italics were not in the first questionnaire.
102
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