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ABSTRACT: OBJECTIVE:: To assess the impact of occupational medicine board certification and career stage on practice characteristics. METHODS:: Two hundred sixty occupational medicine physicians completed a questionnaire and 25 activity log descriptions about 72 items in 9 major domains. For each item, the percentage of activities involving the item and the percentage of physicians conducting the item at least once were calculated. Results were analyzed by board certification status and career stage. RESULTS:: Board-certified physicians had more-diverse practice activities and skills. They were more involved in management and public health-oriented activities, with greater emphasis on toxicology and less on musculoskeletal disorders. The noncertified physicians received more payment from workers' compensation. Early-career physicians spent more time in direct injury/illness treatment, being paid by workers' compensation, and addressing musculoskeletal problems. CONCLUSIONS:: Formal training confers advantages in practice diversity and population medicine orientation.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 04/2013; · 1.88 Impact Factor
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ABSTRACT: OBJECTIVE:: To describe career path patterns for occupational medicine (OM) physicians. METHODS:: A convenience sample of 129 occupational physicians described work activities and locations at several career points up to 20 years ago, first OM position, and 10 years after expectations. RESULTS:: Clinical activities were important throughout (eg, 41% and 46% of occupational physicians reported frequently treating patients 20 years ago and currently). Practice locations changed more markedly, with increased multisite clinics and hospital/medical center-based practices. Performing mainly clinical activities in a first job increased from 82% to 97% over the past 20 years. Career transitions between clinical and nonclinical roles were common (40% of participants). Many anticipate transition to nonclinical work over 10 years. CONCLUSIONS:: Activities have not fundamentally changed, but practice locations have evolved. Both clinical and management activities remain important, and path to managerial positions increasingly begins in clinical practice.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 10/2012; · 1.88 Impact Factor
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ABSTRACT: : To assess country factors associated with the risk of requiring aeromedical evacuation and hospitalization among expatriate workers and their dependents.
: The 2009-2010 data including 5725 aeromedical evacuations and 17,828 hospitalizations, and 2009 data of hospitalizations and aeromedical evacuations among 94,651 at-risk expatriates, were analyzed to assess 2 country risk rating tools. Each tool utilized four risk categories and reflected level of development and medical capabilities.
: Country risk category was strongly associated with risk of evacuation and/or hospitalization for each risk rating tool (eg, 46-fold increase from lowest to highest country risk category).
: Country risk tools strongly associate hospitalization and aeromedical evacuation with country risk category, and thus can be important indicators of relative medical risk. Employers may use these results to implement targeted prevention programs to support expatriate workers and their families.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 08/2012; 54(9):1118-25. · 1.88 Impact Factor
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ABSTRACT: Occupational exposures can contribute to the exacerbation as well as the onset of asthma. However, work-exacerbated asthma (WEA) has received less attention than occupational asthma (OA) that is caused by work.
The purpose of this Statement is to summarize current knowledge about the descriptive epidemiology, clinical characteristics, and management and treatment of WEA; propose a case definition for WEA; and discuss needs for prevention and research.
Information about WEA was identified primarily by systematic searches of the medical literature. Statements about prevention and research needs were reached by consensus.
WEA is defined as the worsening of asthma due to conditions at work. WEA is common, with a median prevalence of 21.5% among adults with asthma. Different types of agents or conditions at work may exacerbate asthma. WEA cases with persistent work-related symptoms can have clinical characteristics (level of severity, medication needs) and adverse socioeconomic outcomes (unemployment, reduction in income) similar to those of OA cases. Compared with adults with asthma unrelated to work, WEA cases report more days with symptoms, seek more medical care, and have a lower quality of life. WEA should be considered in any patient with asthma that is getting worse or who has work-related symptoms. Management of WEA should focus on reducing work exposures and optimizing standard medical management, with a change in jobs only if these measures are not successful.
WEA is a common and underrecognized adverse outcome resulting from conditions at work. Additional research is needed to improve the understanding of the risk factors for, and mechanisms and outcomes of, WEA, and to inform and evaluate preventive interventions.
American Journal of Respiratory and Critical Care Medicine 08/2011; 184(3):368-78. · 11.08 Impact Factor
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ABSTRACT: Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations.
Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility.
Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations.
These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.
Journal of Occupational Rehabilitation 03/2011; 21(1):100-19. · 2.80 Impact Factor
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ABSTRACT: Anxiety may interfere with proper respirator use. This study directly compares the effect of two types of respirators--elastomeric half-face mask with dual-cartridges (HFM) and N95 filtering facepiece--on anxiety levels. Twelve volunteers with normal or mildly impaired respiratory conditions performed a series of simulated work tasks using the HFM and N95 on different days. The State-Trait Anxiety Inventory (STAI) measured state anxiety (SA) before and during respirator use. STAI also measured trait anxiety (TA), a stable personal characteristic. The effect of the respirator was measured as the difference between SA pre-use and during use. Work with HFM was associated with an increase in SA (2.92 units, p < .01), whereas work with the N95 had no observed effect. Anxiety should be considered in the selection of the best respirator for a user. Impact on anxiety should be considered for respirator design and certification purposes, particularly if the device is to be widely used in workplace and community settings.
Journal of Occupational and Environmental Hygiene 03/2011; 8(3):123-8. · 1.19 Impact Factor
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ABSTRACT: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections have been common in prisons for more than a decade. However, CA-MRSA as a cause of pneumonia has been reported infrequently. This infection can present with flu-like symptoms and rapidly progress, possibly leading to death in a matter of days. Two cases of MRSA community-acquired pneumonia (CAP) associated with influenza-like illness in correctional officers employed in two separate prisons within the California prison system are presented. Both individuals were previously healthy, but one died of this disease. MRSA is an uncommon, but now recognized, cause of CAP. These cases are notable for their unique presentation and occurrence in non-health care, occupational settings. Prompt diagnosis and intervention by occupational health nurses and physicians are critical to improving outcomes, especially in high-risk settings such as prisons. These worksites need an effective occupational health program to manage MRSA, with adequate training for both employees and inmates.
AAOHN Journal 03/2011; 59(3):135-40; quiz 141-2. · 0.51 Impact Factor
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ABSTRACT: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections have been common in prisons for more than a decade. However, CA-MRSA as a cause of pneumonia has been reported infrequently. This infection can present with flu-like symptoms and rapidly progress, possibly leading to death in a matter of days. Two cases of MRSA community-acquired pneumonia (CAP) associated with influenza-like illness in correctional officers employed in two separate prisons within the California prison system are presented. Both individuals were previously healthy, but one died of this disease. MRSA is an uncommon, but now recognized, cause of CAP. These cases are notable for their unique presentation and occurrence in non-health care, occupational settings. Prompt diagnosis and intervention by occupational health nurses and physicians are critical to improving outcomes, especially in high-risk settings such as prisons. These worksites need an effective occupational health program to manage MRSA, with adequate training for both employees and inmates.
AAOHN Journal 02/2011; · 0.51 Impact Factor
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ABSTRACT: Respirators are used to maintain work performance and protect against inhaled toxins. The study compared the effects of two commonly used respirator classes--dual cartridge half face mask (HFM) and filtering face piece (N95)--upon work productivity.
107 volunteers performed eight simulated work tasks when using the HFM and N95 respirators. Tasks included several body positions, exertion levels, and concentration requirements. Objective measures of accuracy and speed were developed for each task. Scores for each task were based on the subject's rank among all subjects.
All subjects were capable of performing the tasks. There were no statistically significant differences between respirator types in either task performance metric.
Productivity impact can be measured effectively and should be considered as part of respirator design testing and when selecting the optimal respirator for a worker.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 01/2011; 53(1):22-6. · 1.88 Impact Factor
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ABSTRACT: To characterize activities and skills of occupational physicians using work diaries.
A total of 260 occupational physicians from a national sample provided task/skill descriptions at approximately 25 specific times. The average percentage of activity samples using a skill and the interquartile range expressed results.
Clinical activities, particularly musculoskeletal, were most frequent, followed by industry and health system management. Traditional public health approaches were infrequent. Injured patients, employers, and healthy workers were the most common beneficiaries. Communication about prevention and work restrictions was frequent. Interphysician variability was high for most measures.
Results demonstrated a dichotomy-many frequent activities/skills are associated with other specialties as well (eg, treating injury); others, albeit less frequently used, demarcate the uniqueness of occupational medicine (eg, preventive examinations, toxicology, benefiting employers or worker groups, assessing work ability, payment by employers).
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 12/2010; 52(12):1147-53. · 1.88 Impact Factor
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ABSTRACT: To characterize education, practice, and skills of occupational physicians and to evaluate subgroups within the profession.
The data for the baseline surveys of the occupational medicine practice research project were collected for a national sample of occupational physicians using paper or on-line instruments. Three subgroups were defined a priori-injury care, clinical specialist, and management/population.
Occupational medicine seems to include three distinct subgroups, which differ in characteristics such as patient volume, relevant clinical skills, and income source. Nevertheless, many commonalities were present across all three groups, such as emphasis on communication, OSHA, and workers compensation. Musculoskeletal and workers compensation care were most important, although there were highly significant differences among the three subgroups.
Planning for education, certification, and organization of services should acknowledge the distinctions among the three subgroups.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 07/2010; 52(7):672-9. · 1.88 Impact Factor
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ABSTRACT: To study the prevalence of beryllium sensitization (BeS) and chronic beryllium disease (CBD) in a cohort of workers from a nuclear weapons research and development facility.
We evaluated 50 workers with BeS with medical and occupational histories, physical examination, chest imaging with high-resolution computed tomography (N = 49), and pulmonary function testing. Forty of these workers also underwent bronchoscopy for bronchoalveolar lavage and transbronchial biopsies.
The mean duration of employment at the facility was 18 years and the mean latency (from first possible exposure) to time of evaluation was 32 years. Five of the workers had CBD at the time of evaluation (based on histology or high-resolution computed tomography); three others had evidence of probable CBD.
These workers with BeS, characterized by a long duration of potential Be exposure and a long latency, had a low prevalence of CBD.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 06/2010; 52(6):647-52. · 1.88 Impact Factor
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ABSTRACT: To assess the effect of respirator type and user characteristics (eg, health status) on the subjective response to respirator use.
The subjective responses for multiple domains were evaluated in 104 volunteers performing work tasks in a simulated work environment. Each used a dual cartridge half face mask and a filtering facepiece (N95) respirator. The study population was recruited to include four groups (normal respiratory status, mild asthma, chronic obstructive pulmonary disease, or chronic rhinitis). Mixed model regression analyses determined the effects of respirator type, disease, gender, and age.
Half face mask produced more adverse subjective response than the N95 for most scales. There were significant interactions such that disease status modified the effect of respirator type. In general, women reported greater adverse ratings than did men.
The effect of respirator type depends on disease status. Respirator design evaluation panels should include persons with mild respiratory disease.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 02/2010; 52(2):150-4. · 1.88 Impact Factor
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ABSTRACT: To assess whether mild respiratory disease affects physiologic adaptation to respirator use.
The study compared the respiratory effects of dual cartridge half face mask and filtering facepeice (N95) respirators while performing simulated-work tasks. Subjects with mild chronic obstructive pulmonary disease (n = 14), asthma (n = 42), chronic rhinitis (n = 17), and normal respiratory status (n = 24) were studied. Mixed model regression analyses determined the effects of respirator type, disease status, and the respirator-disease interactions.
Respirator type significantly affected several physiologic measures. Respirator type effects differed among disease categories as shown by statistically significant interaction terms. Respiratory timing parameters were more affected than ventilatory volumes. In general, persons with asthma showed greater respirator-disease interactions than chronic obstructive pulmonary disease, rhinitis, or healthy subjects.
The effects of respirator type differ according to the category of respiratory disease.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 02/2010; 52(2):155-62. · 1.88 Impact Factor
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ABSTRACT: Understanding the progression from beryllium exposure (BeE) to chronic beryllium disease (CBD) is essential for optimizing screening and early intervention to prevent CBD.
We developed an analytic markov model of progression to cbd that assigns annual probabilities for progression through three states: from BeE to beryllium sensitization and then to CBD. We used calculations of the number in each state over time to assess which of several alternative progression models are most consistent with the limited available empirical data on prevalence and incidence. We estimated cost-effectiveness of screening considering both incremental (cost/case) and cumulative program costs.
No combination of parameters for a simple model in which risk of progression remains constant over time can meet the empirical constraints of relatively frequent early cases and continuing development of new cases with long latencies. Modeling shows that the risk of progression is initially high and then declines over time. Also, it is likely that there are at least two populations that differ significantly in risk. The cost-effectiveness of repetitive screening declines over time, although new cases will still be found with long latencies. However, screening will be particularly cost-effective when applied to persons with long latencies who have not been previously screened.
To optimize use of resources, the intensity of screening should decrease over time. Estimation of lifetime cumulative CBD risk should consider the declining risk of progression over time.
Environmental Health Perspectives 07/2009; 117(6):970-4. · 7.04 Impact Factor
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ABSTRACT: Our objective was to determine how to select the optimal frequency of workplace spirometry screening using diacetyl-exposed workers as an example.
A Markov model was constructed to assess the likelihood of progressing from healthy status to early or advanced disease, starting from four different exposure levels, and performing longitudinal or cross-sectional interpretation of spirometry results over time. Projected outcomes at 10 years were evaluated to inform the optimal frequency of workplace spirometry testing.
The optimal screening interval depends on the population risk and is highly sensitive to the real-life impact (utility) associated with false-positive results (eg, related to the availability of alternative work). Screening interval is particularly important for high-risk individuals with rapid transition from early to advanced disease, where the 10-year prevalence of advanced disease would be reduced from 5.3 to 2.5% using a 6-month interval rather than a 12-month interval. Longitudinal test interpretation, based on observing trends within each person over time, is marginally preferable to traditional cross-sectional spirometry interpretation.
There is no single best screening interval. For high-risk populations, annual testing may be too infrequent.
Chest 06/2009; 136(4):1086-94. · 5.25 Impact Factor
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International Archives of Occupational and Environmental Health 06/2009; 83(1):111; author reply 117. · 1.89 Impact Factor
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ABSTRACT: This study compared the physiological impacts of two respirator types in simulated work conditions. Fifty-six subjects included normal volunteers and persons with mild respiratory impairments (chronic rhinitis, mild COPD, and mild asthma). Respiratory parameters and electrocardiogram were measured using respiratory inductive plethysmography while performing eight work tasks involving low to moderate exertion using two respirators: (1) a dual cartridge half face mask (HFM) respirator, and (2) the N95. Mixed model regression analyses evaluating the effect of task and respirator type showed that task affected tidal volume, minute ventilation, breathing frequency and heart rate; all were greater in heavier tasks. Although respirator type did not affect respiratory volume parameters and flow rates, the HFM led to increase in the inspiratory time, reduction of the expiratory time, and increase in the duty cycle in comparison with the N95. The magnitude of differences was relatively small. The results suggest that most individuals, including persons with mild respiratory impairments, will physiologically tolerate either type of respirator at low to moderate exertion tasks. However, because effective protection depends on proper use, differences in subjective effect may have greater impact than physiological differences. Using respirators may be feasible on a widespread basis if necessary for maintaining essential services in the face of widespread concern about an infectious or terrorist threat.
Journal of Occupational and Environmental Hygiene 05/2009; 6(4):221-7. · 1.19 Impact Factor
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ABSTRACT: : Evaluate subjective tolerance to respirator use outside of traditional industrial settings by users including persons with mild respiratory impairment.
: The response to respirator use (half face mask dual cartridge and N95) was measured during eight types of work activities as well as in an exercise laboratory setting. The 43 research subjects included persons with mild respiratory impairments. Multiple domains of subjective response were evaluated.
: Mixed model regression analyses assessing the effect of respirator type and task type showed: 1) most tolerated respirator use well; 2) half face mask respirators typically had greater adverse impact than N95 types; 3) multiple subjective outcomes, rather than only comfort/breathing impact, should be measured; and 4) rated subjective impact during work activities is less than in exercise laboratory settings.
: The results suggest that respirator use may be feasible on a widespread basis if necessary in the face of epidemic or terror concerns.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 02/2009; 51(1):38-45. · 1.88 Impact Factor
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ABSTRACT: Workers' compensation systems increasingly use mandatory treatment guidelines to guide clinicians and for utilization management. This article describes the steps for selecting such guidelines.
On the basis of experience with the RAND/University of California, Los Angeles project to help California select guidelines, we identified the necessary choices and processes for guideline selection and evaluation.
Major steps in guideline selection include: 1) define purpose; 2) assign decision-making authority; 3) decide whether to use existing guidelines or develop new ones; 4) choose whether to use one or multiple existing guidelines; 5) specify clinical topics that guidelines should address; 6) identify and screen guidelines; 7) evaluate guidelines; 8) consider implications of results; 9) select guideline(s); 10) disseminate selection; and 11) assess long-term effectiveness.
Given the many choices required, selecting mandatory workers' compensation guidelines should involve careful planning and a transparent, well-defined process.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 12/2008; 50(11):1282-92. · 1.88 Impact Factor
