OSHA health standards typically require the employer to “furnish the physician” with a copy of the standards (including any appendices); a description of the employee's job duties as they relate to the employee's exposure; the measured or anticipated level of exposure to the hazard; prior tests and written opinion in the employer's control.
These requirements underscore previous discussion about employers' understanding of the requisite skills involved and OSHA's original expectation and acceptance that any licensed physician is prepared and capable of adequately performing a medical surveillance examination (see section Requirements and Competencies). In practice, the physician should be intimately familiar with the standards or compliance program as well as the particularly work process, exposure ranges (recently measured and historical), work practices (and their variations), PPE assignment and usage, and other related aspects of the workplace and hazard prior to undertaking medical surveillance examinations. When the physician needs additional information, the request should be made and documented clearly to the appropriate person at the company/organization.
Beyond this information, criteria for evaluating medical histories, performing physical examination, interpreting test data, and making a determination are largely left to the physician's judgment and only rarely are specified by regulations.
Medical Surveillance Examinations
At the clinical level, physicians participate in medical surveillance by providing medical surveillance examinations and/or interpreting of biological or other physiological monitoring such as pulmonary function testing, audiograms, or chest radiographs. These examinations and tests may be specified by a regulatory standards and/or by a company-or industry-specific policy. The scope of content and reported results is thus dependent on these requirements.
There are overlapping but also distinct purposes and benefits for the employee (patient) and the employer. The purpose of medical surveillance examinations includes one or more of the following.
A. Identify Medical Conditions
For baseline examinations, the physician who conducts a medical surveillance examination reviews the employee's complete health history (including occupational history) and conducts a physical examination. The history focuses on nonoccupational conditions (diseases), undiagnosed symptoms, or a risk factor (eg, family history, habit or lifestyle choice) which may increase an employee's susceptibility to a hazard, or which could be potentially worsened or aggravated as a result of occupational exposure or conditions, or which could impair a worker's ability to safely work in and around a particular hazard. As an example, for a worker with lead exposure, significant conditions could include an underlying renal disease or reproductive disorder; an unexplained history of fatigue and depression; a strong family history of certain neurologic disorders or inherited hemoglobinopathy; or methamphetamine or marijuana usage which may affect cognition and affect. In a worker with potential exposure to asbestos, a history of emphysema or other chronic lung disease, or a current or past cigarette smoking history would be pertinent medical history to document.
The physician's duty is to determine whether an individual is able to safely perform his job, with or without certain restrictions, additional protective measures, or monitoring. On a periodic (eg, annual) basis, if applicable, the physician assesses the employee's interim health status over the preceding period, elucidating any changes in past and querying about new health conditions, including whether they are diagnosed, undiagnosed, treated, or untreated, and their potential association with the occupational hazard in question. It is important for physicians to recognize that medical surveillance is not intended to fulfill the same function as a preemployment (preplacement) physical exam to determine if the employee is able to perform the job (essential functions).
The medical surveillance examination may be labeled by the employer or by the physician for billing purposes as a “preemployment examination” or “preplacement examination,” and the content may include addressing general abilities to perform a particular job, and/or ability to wear PPE, but from a regulatory and preventive perspective the two should not be conflated. Some employers may not realize the distinction or its significance, but it is the physician's duty nonetheless to ensure the proper scope of assessment.
In the course of a baseline medical examination, it is common for a physician to uncover known as well as unidentified preexisting conditions and findings that may or may not be related to the employee's workplace exposure. Examples include elevated blood pressure (hypertension), heart murmur, or benign or potentially malignant skin lesions. The physician has a duty to inform the employee of such findings, including recommendations on seeking medical diagnosis and/or treatment outside of work. The physician may proffer general information and advice about the risks of and recommendations for changing habits and lifestyle behaviors such as smoking, diet, exercise, or substance use. This information must be documented in the physician's notes, but must not be disclosed to the employer. Such admonitions are included in certain OSHA health-based standards.
B. Identify Potential Nonoccupational (and/or Prior Occupational) Sources of Exposure
The medical surveillance examination should identify and, where feasible, quantify the source(s), extent, duration, and potential or actual health effects associated with prior occupational, environmental (eg, residential, dietary) exposure to the same or related toxicants. For example, the occupational history of employees entering a cadmium or lead surveillance program who previously worked for other employers in the same industry or other industries should be thoroughly documented.
In practice, obtaining and documenting this information can be very challenging for the physician. The employer often does not have access to this detailed information, either from the employee, the former employer, or governmental regulatory agencies. The employee may or may not accurately or completely recall his/her job title, or the results of examinations, biological monitoring tests, or exposure data. In many instances, the employee will not have received or kept copies of his/her medical opinions and test results. In selected cases in which a new employee's current risk in his/her new job can be impacted by unknown or incomplete past such occupational information, the physician has an implicit obligation to request it and review it—even though regulatory agencies such as OSHA have no such requirements or provisions for compelling employees or their former employers from doing so. The physician should carefully document his/her concerns and requests, as well as follow-up communications and findings, in the medical record.
Environmental exposures to toxicants may occur as a result of residential conditions, hobbies, diet, or other recreational activities. Questions of this nature on standard forms may or may not elicit affirmative responses. The questions require carefully reiteration and detailed scrutiny by the physician to determine if and to what extent the information (or lack thereof) may be important at that time or in the future.
Sometimes a new employee's baseline laboratory or physiological tests performed at the time of the medical surveillance examination reveals an abnormality(ies) that may reflect a known or unknown, preexisting or latent medical condition or risk factor. For example, an employee who begins new employment in a lead-exposed job with a “baseline” blood lead level of 35 ug/dL, or who has a microcytic/hypochromic anemia, may have acute and/or chronic health risks that reflect recent and/or past occupational lead exposures or underlying blood loss or erythrocyte production disease. These findings may warrant the physician to obtain prior medical records. They may necessitate further medical evaluation outside the scope of the examining physician's purview to obtain a diagnosis from which the physician can more fully evaluate the employee's risk and advise on any necessary limitations or monitoring requirements. The employer, who is entitled to laboratory information, should be informed that a preexisting condition exists to explain the abnormality, but for confidentiality (privacy) reasons the physician should not disclose the documented or suspected diagnosis.
C. Detect Early Symptoms or Signs of Excessive Exposure and/or Adverse Effects
Perhaps the most widely recognized reason for and function of the medical surveillance examination is to detect clinical evidence—symptoms or signs—of early adverse effects related to the occupational exposure/hazard.
Some surveillance programs require periodic (typically annual) surveillance examinations, or this requirement is triggered if an employee's biological monitoring test result within a given period has exceeded a minimum regulatory threshold. Many OSHA health standards contain a provision that if the employee “has symptoms or signs of toxicity,” he/she or the employer may/must request a medical surveillance examination. Obvious confidentiality issues and problems are associated with compelling and relying upon an employee to initiate and document a “complaint” to his/her employer about symptoms, or revealing findings to a company-appointed doctor that may have intended or have been afraid to address with the employee's personal physician (see section Ethical Considerations). It is not uncommon for an employee to present for a regularly scheduled surveillance examination with ongoing health complaints that could—and should—have been raised earlier by notifying the employer and/or his/her physician. Such caveats are one reason for why so many occupational diseases are under-reported and diagnosed so late.
Health outcomes in most medical surveillance examinations are either symptoms—alone or in combinations, each with a temporal pattern and distribution that needs to be characterized—or signs of disease, such as a physical examination or laboratory test finding. Signs may be symptomatic or asymptomatic; and the symptoms may or may not coincide with the symptoms obtained during this history. Symptoms may or may not be work- or exposure-related; and their cause and relationship to one another may not be obvious to the employee, the employee's personal physician, or the employer. Nor may certain symptoms, “complaints,” or diagnoses be ones that employers are willing to volunteer to their employer or to the physician.
When a symptom(s) or concern is presented by an employee to the physician, making the correct diagnosis (or exclusion) of an occupational disease can be a challenging, time consuming, and often frustrating process. Even when a diagnosis is not definitive, subtle trends in exposure or health effects that may not be immediately recognized or diagnosed accurately on an individual basis may nonetheless impact a group of workers over time, sometimes after long periods of time or after exposure has ceased. It is especially important for the physician to recognize that certain occupational diseases commonly do not present with “specific” or “classic” symptoms or signs, particularly in their early or subacute phase.
The diagnostic (forensic) process of assessing symptoms for possible occupational toxicity/disease is a key part of residency training in occupational medicine. This process occurs during the medical surveillance examination wherein the physician utilizes all the available, pertinent information: the in-person medical “history”—reviewing/evaluating prior health information obtained during the baseline and any previous examinations; documenting current symptoms (onset, timing, severity, and association with other symptoms) and whether or not the condition has been diagnosed or treated (either by a physician, other health care practitioner, or by the patient); review of any biological monitoring or other data; review of exposure monitoring data, taking into account knowledge of the employee's actual work duties and work practices and documenting any changes in work practices; and PPE usage.
An objective, thorough synthesis and analysis of this information requires an in-depth understanding of the hazard and its related toxicology or pathophysiology. The physician must understand the toxicology, natural history, and variable clinical presentations of occupational diseases, and be able to formulate a cogent, relevant differential diagnosis for plausible nonoccupational diseases, taking into account the temporality of clinical findings in association with job-specific risk factors. The physician must recognize that many occupational diseases do not present with overt signs or may have reversible effects that may not be apparent during a one-time examination. A pertinent review of systems should address the differential diagnosis, with interpretation and documentation of both pertinent positives and negatives. Similarly, the physical examination should address both pertinent positive and negative findings associated with toxicity as well as applicable potential differential diagnoses of nonoccupational diseases and conditions.
Beyond the individual employee's clinical findings, the physician should seek objective information to determine if similar symptoms/findings have occurred among the employee's coworkers (present or past). This may necessitate collection and/or statistical analysis of aggregate and temporal data which, as previously discussed, may or may not be available from the employer. If the hazard is not specifically regulated and/or the employer does not have a written medical surveillance program, information about the toxicology of the hazard must be obtained. If the physician is not already familiar with the company, its processes, and the particular job in question, a site visit should be conducted. Depending on the physician's relationship with the employer, the employer may or may not be willing to adequately compensate the physician for his/her time to perform this assessment, and/or provide the physician with the requested information with which to make an informed determination. This situation is one example of the type of potential ethical dilemmas faced in occupational medicine practice that most physicians in other specialties may not recognize.
If the physician determines that a symptom or sign is an effect of toxicity or resulting from exposure-related aggravation of an underlying medical condition (which may or may not have been previously documented), the basis of this determination should be thoroughly documented. The physician should carefully inform the employee of the findings, including what measures will be recommended to minimize further harm, monitor the employee's health, or correct workplace conditions that have caused or contributed to this problem. The employer must be informed by the physician of the same (in writing), while respecting the employee's right to confidentiality, particularly of unrelated or personal health information.
D. Monitor Trends to Assess Efficacy of Exposure Controls and Need for Program Modifications
As medical surveillance is commonly defined, systematic tracking of information over time and among similarly exposed groups (SEGs) within a company and/or industry is a primary goal of medical surveillance. In practice, this process is actually rarely conducted in its intended scope at the clinical level. When it is performed by the employer, it is usually limited to analysis of surrogate markers (eg, blood lead levels for lead medical surveillance) using simple summary statistics. Physicians who practice outside of companies, even though they provide medical surveillance examinations, are rarely involved in the internal evaluation of the effectiveness of the surveillance program.
The OSHA health standards and most other countries' comparable standards require determinations of specific parameters such as biological monitoring or examinations to be “analyzed” on a one-at-a-time, employee-by-employee basis. In effect, if the employee “passes,” the employer (and physician) puts the information in a folder (paper or electronic) and leaves it there until the next scheduled examination. Beyond certain parameters such as biological monitoring data being tabulated in a spreadsheet, the rest of the information typically remains unutilized unless an employee-specific problem arises.
Neither OSHA nor MSHA nor NIOSH requires or offers guidance on tools for companies to measure outcomes and trends to assess compliance program performance. Similarly, no professional occupational medicine organization (eg, American Medical Association [AMA], American College of Occupational and Environment Medicine [ACOEM]) offers such tools to its physician members. Physician who practice in groups or clinics where different physicians—or other health care professionals such as nurses—examine employees from the same company may not have information systems, or devote any time or resources to share information and identify potentially significant aggregate problems.
As previously discussed, employers find managing the ongoing, complex requirements of health-based compliance programs to be demanding. Administration of health-based compliance program data tends to be especially time consuming, inefficient, and error-prone if it is not systematically managed and automated. Data errors or omissions that go undetected can be propagated over time and impact multiple employees.
Because the risk and disease endpoint is not a discrete event like an accident or lost workday, the complexity of information and applicability to each employee is highly variable. As a result, compliance data and tracking are highly prone to errors, oversights, missing information, and misinterpretation.
OSHA standards were largely developed and promulgated in the 1970s and early 1980s, before the advent of personal computers or databases. To this time, most employers (and their suppliers including physicians) continue to manage such information using paper-based files and folders, or homemade spreadsheets or checklists intended for specification-based safety standards. These methods, some of which are “computerized,” are not automated. They are neither robust nor flexible enough to efficiently manage health-based compliance program requirements and data. For example, they are not designed to catch errors, automatically flag and track variable schedules, or provide one-click critical statistical analyses. These limitations create serious, unwanted compliance vulnerability for the company and its employees.
Affordable automated systems that are specific for particular hazards (eg, lead, noise, respiratory protection) customizable to specific company and regulatory requirements are commercially available for employers. Such systems enable employers to manage all their compliance program activities and data, including scheduling, tracking/follow-up, collection, data analysis, and reporting and documentation, enabling them to manage information in a truly seamless manner that minimizes the risk of errors and oversights. Employers who recognize the value of automating and utilizing their health and safety data to go “beyond compliance” to perform valuable business functions are able to save time and resources while better protecting their employees' health by having the ability to measure compliance program effectiveness, identify areas that require further attention, and measure the impact of investments in exposure controls.
Physicians may have an opportunity to access such systems as an authorized user. Some physicians have practice management software that allows them to compile and track certain data such as pulmonary function tests or vaccinations, but often such programs do not provide useful data to employers (See Chapter 5).