Public Health Law Map - Beta 5 - Medical and Public Health Law Site

Occupational medicine is one of the three subspecialties certified by the Board of
Preventive Medicine. It is a subspecialty of preventive medicine because occupational
medicine physicians must practice primary prevention, evaluating the short-term and
long-term hazards of the workplace as they relate to people and disease. In the 40- year
history of the board, only a few thousand physicians have become board certified in
occupational medicine. This certification assumes competence in general medicine and
minor emergency care, toxicology, environmental medicine (heat, physical stress, etc.),
ergonomics, and job fitness evaluations.
In general, it is ethically questionable for physicians to offer services they are not
properly qualified to perform. Occupational medicine poses a particular problem
because the employee usually has no right to refuse the physician’s services or seek
alternative care. There is a special duty to protect patients who are in coercive
environments. Employees are peculiarly dependent on the occupational medicine
physician’s expertise for protection them from workplace hazards. It is anticipated that
occupational medicine physicians will seek information about hazards, even if that
information involves a trade secret. Independent contractor physicians with limited
access to the workplace and no detailed knowledge of workplace environment cannot
effectively protect their employee patients from hazards and toxic exposures.
In several specific situations, state or federal regulations mandate special training or
certification for physicians performing a regulated activity. The most widely known
are the Department of Transportation regulations on who may do physical
examinations of licensed pilots. Only a Federal Aviation Administration–approved
flight surgeon is allow to perform these exams. Yet even simple activities such as
reading routine X rays of industrial employees may require a special certification.
Physicians who read chest X rays on workers exposed to asbestos must be certified for
the readings to satisfy OSHA surveillance requirements. In some instances, the OSHA
regulations require occupational medicine physicians to refer workers to specialists. If
the white blood cell count on a benzene-exposed worker falls below a certain level, the
occupational medicine physician must refer the patient to a hematologist for further
evaluation.
Despite the special nature of occupational medicine practice, most ambulatory care
centers, minor emergency clinics, and group practices hold themselves out as offering
occupational medicine services. Until recently this meant preemployment physical
examinations and treatment for acute workplace injuries. Increasingly, however, these
entities are contracting with employers to provide services that are expected to be
professionally comparable to in-house occupational medical services provided by
experienced occupational medicine professionals. These contracts subject such
providers to the full panoply of state and federal regulations.
Outside occupational medicine providers are handicapped by their isolation from the
workplace. They are generally limited to second- hand, fragmented information about
working conditions and workplace exposures, yet determining job fitness requires
detailed information about both the job and the workplace. If they also provide the
employee’s general medical care, they are faced with significant questions about the
segregation of job-related and personal medical information. Moreover, the checks
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