OEM Program

• General program Information
• Staff
• Education
• Research
• Consultative Services
• Consultation Requests
• Health Information
• Computer Modules
• Publications

AgMed Program

PREFACE STANLEY H. SCHUMAN, M.D., DR. P.H The purpose of this book is to fill an unmet need. A number of available excellent books deal with Environmental and Occupational Medicine (EOM) exposures in a manner that is too diverse and detailed for the busy clinician in primary care. The organization of the mass of cumulative facts derived from environmental chemistry, toxicology, engineering and the clinical practice of what used to be called "industrial" medicine is commendable. However, these multi-authored compendiums reinforce the overwhelming nature of the data base which the specialist must use, but which the busy primary care clinician can only wish to acquire, someday, when he finds the precious time. Of course, computer access may help bridge the gap between too much and too little information. ISBN 90-5702-510-8 Harwood Academic Press

In the meantime, the clinician finds himself in the clinic, the operating room, the emergency room, or on hospital rounds, or at a work-site visit caught among three dilemmas: (1) the worker/patient's need for a caring, competent physician; (2) managed care's demand for a 15 minute aliquot of curative or preventive service; and (3) an encyclopedic expanding EOM data base. The latter consists of 1, 000 page textbooks and a computerized EPA/IRIS (Integrated Risk Information System) which provides access "as of June 1, 1995 to 527 chemicals, 350 oral reference dose (RFD) summaries, 95 inhalation references (RFC), 220 carcinogen assessments, for a total of 665 health hazard information summaries, 73 chemical specific Drinking Water Health Advisories, 389 EPA regulatory action summaries, and bibliographic citations for 512 substances". (reference: Mettner JM: Keeping up with I.R.I.S., Health & Environ Digest 9:28, 1995).

No wonder the physician feels overwhelmed by EOM in a way that is different from the information overflow he receives from disciplines such as immunology, infectious disease, drug interactions, etc. Yet he must face the presenting illness of the patient/worker with a real or potential EOM component on a daily basis. In fact, at least 76% of EOM services for industries and companies nationwide in the U.S. are delivered by primary care physicians and only 24% by trained EOM specialists (reference: OSHA: Final Report: Description and Evaluation of Medical Surveillance Programs in General Industry and Construction [p.I-18] Stevens Publishing Corp., Washington, DC 20045, 1993).

A statewide survey of a random sample of 100 actively practicing family physicians in Oregon in 1991 achieved a 93% response rate. (Goodwin P, Wall EM, Bajorek M: Occupational medicine content of Oregon family physician practices. JABFP 8:300-304, 1995.) The mean percentage of time spent with "occupational health problems" was 14%. The rank order of frequency of EOM problems seen was: (1) acute trauma; (2) management of chronic disability; (3) repetitive trauma disorders; (4) disability determination; (5) preplacement physical examinations; and (6) occupational stress. The authors of this survey make a plea for more relevant curriculum for primary care clinicians to prepare them for frequent rather than infrequent conditions seen by specialists at the academic center. More emphasis on preventive aspects of EOM in primary care was urged. Broader issues of physician responsiveness to environmental community concerns was not included in this survey on traditional EOM curriculum topics. Perhaps this is because the authors believe that a realistic approach to improved training must be gradual, and outpatient-centered before it can include environmental or life style issues. The newer frontier in EOM curriculum will include career change, job security, quality of housing, air, water, soil pollution, shift work and sleep deprivation, recreational drugs, workplace harassment, sports medicine and rehabilitation. These are leadership issues for preparing a better qualified primary care physician for the near future.

The goals of this book will focus on combining the essential skills of epidemiology (observation, reasoning), EOM (hazard assessment and management) and primary care (listening and caring; diagnosis, treatment or referral; health education and follow-up). All of this to be achieved within the real-world unit of primary care: the 15 minute patient/doctor encounter!

Any book that attempts less than a three discipline approach will fall short of meeting the busy clinician's need to reinforce his considerable skills and experience. One should not intimidate him or her with excessive specialty information, unnecessary referrals, or lists of potential environmental health hazards (at parts per billion over a 70 year lifetime exposure, based on near-lethal dose rodent models) for the growing numbers of useful technologies in our society. At the same time, the modern clinician in a group practice must be as concerned about a series of patients with a common exposure as with a single patient; they must be aware of the sources of hazard to the household or the factory, the neighborhood, the school, the park and recreation site, the highway, the air, water, soil, and food exposures that are relevant to the human health aspects of the community.

The tool of choice in this book is the concise clinical case study. The outpatient setting is where the challenges occur and where signs and symptoms, and objective and subjective evidence must be sorted out. The most effective doctor-patient visit results from the balance of content (knowledge), process (behavior) and motivation (attitude). This a shared responsibility for the health care provider and for the active patient-learner (the healer and the healed).

An impossible task for a single-author, user-friendly book? Of course. To paraphrase the great French essayist, Montaigne, in the preface to his essays in 1580, "Dear reader, if you are seeking perfection in this book, look elsewhere;" or if you wish to master the realms of the specialty of EOM including administrative details, ethical considerations, toxicokinetics and epidemiologic design, look elsewhere. If you seek useful guidelines for your practice, read on...

Reference: Frame DM: Selections From The Essays by Montaigne, Stanford University Press, Palo Alto, CA, 1973