This article was downloaded by: [University of Illinois at Urbana-Champaign] On: 29 January 2015, At: 19:49 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Archives of Environmental Health: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzeh20
In-Plant Medical Services Robert R. J. Hilker MD
a
a
Illinois Bell Telephone Company , 60606, 212 W Washington St, Chicago , IL Published online: 02 May 2013.
To cite this article: Robert R. J. Hilker MD (1975) In-Plant Medical Services, Archives of Environmental Health: An International Journal, 30:8, 409-411, DOI: 10.1080/00039896.1975.10666735 To link to this article: http://dx.doi.org/10.1080/00039896.1975.10666735
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
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In the Forum
In-Plant Medical Services Robert R. J. Hilker, MD
W
hen I started to write these remarks, I was quite sure that the differences between an in-plant medical program and a contract program would be very obvious and very easy to explain. As I developed what I am about to say the differences became less obvious and my remarks much more difficult to differentiate and justify. In fact, Dr. Tabershaw and I may very well come up with a similar conclusion. That conclusion might be that the success of any program is most likely much more dependent on the ingenuity, motivation, competence, and integrity of the physician involved rather than by whom the physician is paid! Nevertheless, I do have some rather definite views on several advantages of an in-plant program that I will share with you. Some theoretical advantages would be: 1. Immediate in-plant availability of medical services by an in-plant physician. 2. The in-plant physician, dealing with only one plant would know jobs,
Submitted for publication May 23, 1974; accepted Jan 21, 1975. From Illinois Bell Telephone Company. Read before the 26th Annual Meeting of the American Academy of Occupational Medicine, San Francisco, March 13, 1974. Reprint requests to the Illinois Bell Telephone Company, 212 W Washington St, Chicago, IL 60606 (Dr. Hilker).
Arch Environ Health/Vol 30, Aug 1975
policies, union contracts, and benefit plans much better than a contract physician. 3. The in-plant physician can devote more time and develop more expertise in administrative medical department activities. 4. The in-plant physician knows the problems of the business better. 5. The in-plant physician likely would have more loyalty to the plant, its employees, and their unions since he is in reality a vital part of their team. 6. The in-plant physician is more likely to be a stable long-term employee who can develop better rapport with management, employees, and unions. 7. Participation in management decisions regarding the health, welfare and safety of employees is an advantage of the in-plant physician. S. The ability to call attention of very top management to problems that seem serious enough to do so is another advantage. I suppose I could add further arguments to this list but it would be somewhat redundant to do so. It should be pointed out that if the contract physician works regular parttime hours in the plant, and especially if the contract is for full-time work in a particular plant, some of the advantages of the in-plant physician would not exist at all or most certainly would be modified. Let me say a few words of qualifica-
tion about requirements for an inplant program to be effective. Though they are well-known, I believe certain things should be reiterated. 1. The plant must be large enough to support a qualified medical department. 2. The medical department must not be a tool of management. 3. The personnel must be of the utmost competence in occupational medicine. 4. Medical records must be confidential except where disclosure is required by law. 5. Cooperation with unions is essential. So far, I have dealt in generalities. What are the specifics of a medical program that would be most beneficial to the industry and its employees? I believe the basic in-plant occupational health program should include these essential parts. 1. Some form of applicant evaluation. 2. Preplacement and periodic examinations for certain strenuous or hazardous jobs or where required by law. 3. Medical care for nonwork-related emergency sickness or accidents. 4. Complete care for work-related injury or illness. 5. Advice to operating departments about the ability of specific employees to carry out the job in a satisfactory manner-that is, a health evaluation program or fitness examination. In-Plant Medical Services/Hilker
409
Downloaded by [University of Illinois at Urbana-Champaign] at 19:49 29 January 2015
6. Advice to operating departments about employees returning from disability, with addition of a fitness examination if necessary. This should include direct medical reporting to the medical department on all disability cases. 7. Participation in an absence control program. S. Presentation of rehabilitation programs particularly for emotionally ill employees, alcoholism, and drug abuse. 9. Advice to operating departments about health effects of working conditions. 10. Advice to operating departments about government regulations and their implications to the industry. 11. Availability to give health advice to employees about themselves or members of their families and, when indicated, serve as a mechanism of entry into the medical care system. 12. Development of a continuous allemployee health education program. 13. Research, either basic or clinical, on a regular basis and contribution of this knowledge to the medical literature. Interesting cases should be sought and reported. 14. Involvement in teaching occupational medicine and arrangements for the medical department to be used for teaching in those locations where it would be appropriate. 15. Active participation in the safety program of the company either by having safety as a part of the medical department or by participating actively in the safety program. 16. Participation as a satellite of an HMO System, if the company is engaging in this type of health care in their benefit program. 17. Advice to management about the desirability and feasibility of health care and insurance packages to be offered or negotiated. I understand that what I have described may be termed an ideal to be reached rather than a practical program for all industry at this time. Nonetheless, I feel that it quite accurately describes the direction that occupational medicine must necessarily take if it is to survive as a viable specialty. It seems reasonable to me 41 I)
Arch Environ Health IVol 30, Aug 1975
that conducting such a program would be much more simply done by an inplant physician. There are many overlapping parts of this program that all dovetail together when they are done in-plant and in reality all become part of an integrated large functional program of the greatest possible efficiency. It can be said that a well-trained contract physician can certainly do any or all of these things. This may quite possibly be true. But, should that be the case, the job can certainly be done with more efficiency within the plant. A review of the activities of contract physicians would also indicate they are most interested in the medical and surgical portions of occupational medicine and have devoted little time or effort to the administrative aspects of our field or to the behavioral problems. There is no doubt that behavioral illness is the largest problem in health that confronts business today. Inplant programs have been remarkably successful in the rehabilitation of employees with emotional illness, alcoholism, and drug abuse. These programs, I submit, are successful because they are in-plant programs. The physician can use his status to apply "constructive coercion" to both management and the employee alike. Jobs can be altered or changed much easier by in-plant physician. Delicate union problems in this area can be handled much better. Follow-up is much better. In our own experience in Illinois Bell Telephone Company we know we have well-accepted and successful programs. For instance, we have been able to cut our number of cases of emotional illness in half and reduce the number of days off by half for those cases we still have. We have a rehabilitation rate of 72% in our alcoholism program. This is in sharp contrast to much lower rates of rehabilitation in those industries in our community who use the same outside treatment sources we do, but do not have an in-plant program. Our experience with drug abuse is interesting. By utilizing our own identification program, but using outside community resources for treatment, we had to admit our program was at best of
minimal success. We could not have recommended it be continued. We made the decision to try an in-plant program modeled after our alcoholism program. Weare now achieving a rehabilitation rate of 75%. I do not know of any program being conducted by contract physicians in these key areas-the single largest health problems in industry today. Nor, do I know of any important contribution to the medical literature in these areas by contract physicians. In the area of absence control, inplant physicians have been far more effective and active. Let Ipe assure you that I do not believe the medical department should be the "policeman" for the benefit or insurance plan. Rather, it should see that the plan is administered equitably for both management and other employees. Days off for illness or accident should be held to a minimum consistent with good medical practice. The first requirement of this is direct medical reporting to the m~dical department and a full review of all insurance reports by, or under the direction of, a physician. The reports should be compared immediately with the medical record of the employee. Patterns of illness suggesting need for a health evaluation or fitness examination will immediately become obvious. Those employees who are receiving suboptimal medical care will also become obvious. Indeed the life of one of the employees in my own department was very likely saved by the astute observations of the physician reviewing our disability certificates. By intervening in the case, adequate medical care was arranged. The help of the medical department should be available to every employee on disability even though it be no more than a telephone consultation. Using the disability statistics, health records and known work status of employees, periodic review of problem employees should be held with the operating departments. We have found that 50% of problem employees do indeed have health problems. Many of these can be substantially improved by offering them a health evaluation and by the medical department taking an interested active role in their treatment and rehaIn-Plant Medical ServiceslHilker
Downloaded by [University of Illinois at Urbana-Champaign] at 19:49 29 January 2015
bilitation. By using the basics of this type of program we at Illinois Bell were able to save $1,500,000 in our budgeted disability payments during the last year. Health education should be an integral part of any occupational medical program. Yet this a field in which even in-plant physicians have taken an interest only recently. I know of no contract physicians who are apparently interested or are active in this field. Health education can and should take many forms-films, articles in employee publications, pamphlets, booklets, lectures to employees, and other ingenious methods. One can ask whether this type of program really is as beneficial as one would hope. Measurements of the success of such a program are admittedly difficult. We recently-and inadvertently-had some measure of the success of our efforts. We, together with a similar public utility in Chicago, are cooperating through Northwestern cooperating Medical School, in a five-year national study of hypertension sponsoredThe the Department of Health, Department and Welfare. The other industry offers an annual examination to all employees. We, in contrast, have a
Arch Environ Health /vol 30, Aug 1975
health education program. As expected, the same number of hypertensives were found in both our employee populations. But, completely unexpected was the fact that twice as many of our employees were receiving optimum treatment as were those of the other public utility. Part of this certainly is due to our long-standing continued health education efforts. Again, contract physicians have evidenced little or no interest or expertise in the field of safety. Yet this is a legitimate-even necessarymedical department function. As the Occupational Safety and Health Act becomes more of an everyday reality in all of our lives, I suspect staff safety will become a medical department function. We have this responsibility now at Illinois Bell. Believe me, it is difficult to do from within the plant. I think it would be virtually impossible for a contract physicianother than one full-time to the plant premises-to conduct such a program. The contract physicians are much less likely to be able to give advice about the health effects of working conditions in a specific plant. Since their exposure is basically only to employees, and since they rarely have a chance to view the work situation at
first hand, their knowledge of each job is less. The in-plant physician is able to discuss working conditions with management, unions, and employees. Seeing the job conditions first hand is both easy and relevant. This also makes interpretations of government regulations and their impact on the industry much easier for the in-plant physician. I have tried to be objective-not argumentative; to be constructivenot destructive. I simply feel there are certain limitations of motivation, of time, of physical location, and of influence within the company that prevent the contract physician from being the "complete" occupational physician at the present time. However, in all fairness I must remind you that my remarks do not apply to the small plant in which more than 50% of all people work. The problem of health care for these employees can and will be solved only by contract physicians. While contract physicians today cannot offer a complete program, I can well visualize the time in the future where contract clinics, combining the resources of several or many industries, can and will conduct a full occupational medical program.
In-Plant Medical Services/Hilker
411
Archives of Environmental Health: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzeh20
In-Plant Medical Services Robert R. J. Hilker MD
a
a
Illinois Bell Telephone Company , 60606, 212 W Washington St, Chicago , IL Published online: 02 May 2013.
To cite this article: Robert R. J. Hilker MD (1975) In-Plant Medical Services, Archives of Environmental Health: An International Journal, 30:8, 409-411, DOI: 10.1080/00039896.1975.10666735 To link to this article: http://dx.doi.org/10.1080/00039896.1975.10666735
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Downloaded by [University of Illinois at Urbana-Champaign] at 19:49 29 January 2015
In the Forum
In-Plant Medical Services Robert R. J. Hilker, MD
W
hen I started to write these remarks, I was quite sure that the differences between an in-plant medical program and a contract program would be very obvious and very easy to explain. As I developed what I am about to say the differences became less obvious and my remarks much more difficult to differentiate and justify. In fact, Dr. Tabershaw and I may very well come up with a similar conclusion. That conclusion might be that the success of any program is most likely much more dependent on the ingenuity, motivation, competence, and integrity of the physician involved rather than by whom the physician is paid! Nevertheless, I do have some rather definite views on several advantages of an in-plant program that I will share with you. Some theoretical advantages would be: 1. Immediate in-plant availability of medical services by an in-plant physician. 2. The in-plant physician, dealing with only one plant would know jobs,
Submitted for publication May 23, 1974; accepted Jan 21, 1975. From Illinois Bell Telephone Company. Read before the 26th Annual Meeting of the American Academy of Occupational Medicine, San Francisco, March 13, 1974. Reprint requests to the Illinois Bell Telephone Company, 212 W Washington St, Chicago, IL 60606 (Dr. Hilker).
Arch Environ Health/Vol 30, Aug 1975
policies, union contracts, and benefit plans much better than a contract physician. 3. The in-plant physician can devote more time and develop more expertise in administrative medical department activities. 4. The in-plant physician knows the problems of the business better. 5. The in-plant physician likely would have more loyalty to the plant, its employees, and their unions since he is in reality a vital part of their team. 6. The in-plant physician is more likely to be a stable long-term employee who can develop better rapport with management, employees, and unions. 7. Participation in management decisions regarding the health, welfare and safety of employees is an advantage of the in-plant physician. S. The ability to call attention of very top management to problems that seem serious enough to do so is another advantage. I suppose I could add further arguments to this list but it would be somewhat redundant to do so. It should be pointed out that if the contract physician works regular parttime hours in the plant, and especially if the contract is for full-time work in a particular plant, some of the advantages of the in-plant physician would not exist at all or most certainly would be modified. Let me say a few words of qualifica-
tion about requirements for an inplant program to be effective. Though they are well-known, I believe certain things should be reiterated. 1. The plant must be large enough to support a qualified medical department. 2. The medical department must not be a tool of management. 3. The personnel must be of the utmost competence in occupational medicine. 4. Medical records must be confidential except where disclosure is required by law. 5. Cooperation with unions is essential. So far, I have dealt in generalities. What are the specifics of a medical program that would be most beneficial to the industry and its employees? I believe the basic in-plant occupational health program should include these essential parts. 1. Some form of applicant evaluation. 2. Preplacement and periodic examinations for certain strenuous or hazardous jobs or where required by law. 3. Medical care for nonwork-related emergency sickness or accidents. 4. Complete care for work-related injury or illness. 5. Advice to operating departments about the ability of specific employees to carry out the job in a satisfactory manner-that is, a health evaluation program or fitness examination. In-Plant Medical Services/Hilker
409
Downloaded by [University of Illinois at Urbana-Champaign] at 19:49 29 January 2015
6. Advice to operating departments about employees returning from disability, with addition of a fitness examination if necessary. This should include direct medical reporting to the medical department on all disability cases. 7. Participation in an absence control program. S. Presentation of rehabilitation programs particularly for emotionally ill employees, alcoholism, and drug abuse. 9. Advice to operating departments about health effects of working conditions. 10. Advice to operating departments about government regulations and their implications to the industry. 11. Availability to give health advice to employees about themselves or members of their families and, when indicated, serve as a mechanism of entry into the medical care system. 12. Development of a continuous allemployee health education program. 13. Research, either basic or clinical, on a regular basis and contribution of this knowledge to the medical literature. Interesting cases should be sought and reported. 14. Involvement in teaching occupational medicine and arrangements for the medical department to be used for teaching in those locations where it would be appropriate. 15. Active participation in the safety program of the company either by having safety as a part of the medical department or by participating actively in the safety program. 16. Participation as a satellite of an HMO System, if the company is engaging in this type of health care in their benefit program. 17. Advice to management about the desirability and feasibility of health care and insurance packages to be offered or negotiated. I understand that what I have described may be termed an ideal to be reached rather than a practical program for all industry at this time. Nonetheless, I feel that it quite accurately describes the direction that occupational medicine must necessarily take if it is to survive as a viable specialty. It seems reasonable to me 41 I)
Arch Environ Health IVol 30, Aug 1975
that conducting such a program would be much more simply done by an inplant physician. There are many overlapping parts of this program that all dovetail together when they are done in-plant and in reality all become part of an integrated large functional program of the greatest possible efficiency. It can be said that a well-trained contract physician can certainly do any or all of these things. This may quite possibly be true. But, should that be the case, the job can certainly be done with more efficiency within the plant. A review of the activities of contract physicians would also indicate they are most interested in the medical and surgical portions of occupational medicine and have devoted little time or effort to the administrative aspects of our field or to the behavioral problems. There is no doubt that behavioral illness is the largest problem in health that confronts business today. Inplant programs have been remarkably successful in the rehabilitation of employees with emotional illness, alcoholism, and drug abuse. These programs, I submit, are successful because they are in-plant programs. The physician can use his status to apply "constructive coercion" to both management and the employee alike. Jobs can be altered or changed much easier by in-plant physician. Delicate union problems in this area can be handled much better. Follow-up is much better. In our own experience in Illinois Bell Telephone Company we know we have well-accepted and successful programs. For instance, we have been able to cut our number of cases of emotional illness in half and reduce the number of days off by half for those cases we still have. We have a rehabilitation rate of 72% in our alcoholism program. This is in sharp contrast to much lower rates of rehabilitation in those industries in our community who use the same outside treatment sources we do, but do not have an in-plant program. Our experience with drug abuse is interesting. By utilizing our own identification program, but using outside community resources for treatment, we had to admit our program was at best of
minimal success. We could not have recommended it be continued. We made the decision to try an in-plant program modeled after our alcoholism program. Weare now achieving a rehabilitation rate of 75%. I do not know of any program being conducted by contract physicians in these key areas-the single largest health problems in industry today. Nor, do I know of any important contribution to the medical literature in these areas by contract physicians. In the area of absence control, inplant physicians have been far more effective and active. Let Ipe assure you that I do not believe the medical department should be the "policeman" for the benefit or insurance plan. Rather, it should see that the plan is administered equitably for both management and other employees. Days off for illness or accident should be held to a minimum consistent with good medical practice. The first requirement of this is direct medical reporting to the m~dical department and a full review of all insurance reports by, or under the direction of, a physician. The reports should be compared immediately with the medical record of the employee. Patterns of illness suggesting need for a health evaluation or fitness examination will immediately become obvious. Those employees who are receiving suboptimal medical care will also become obvious. Indeed the life of one of the employees in my own department was very likely saved by the astute observations of the physician reviewing our disability certificates. By intervening in the case, adequate medical care was arranged. The help of the medical department should be available to every employee on disability even though it be no more than a telephone consultation. Using the disability statistics, health records and known work status of employees, periodic review of problem employees should be held with the operating departments. We have found that 50% of problem employees do indeed have health problems. Many of these can be substantially improved by offering them a health evaluation and by the medical department taking an interested active role in their treatment and rehaIn-Plant Medical ServiceslHilker
Downloaded by [University of Illinois at Urbana-Champaign] at 19:49 29 January 2015
bilitation. By using the basics of this type of program we at Illinois Bell were able to save $1,500,000 in our budgeted disability payments during the last year. Health education should be an integral part of any occupational medical program. Yet this a field in which even in-plant physicians have taken an interest only recently. I know of no contract physicians who are apparently interested or are active in this field. Health education can and should take many forms-films, articles in employee publications, pamphlets, booklets, lectures to employees, and other ingenious methods. One can ask whether this type of program really is as beneficial as one would hope. Measurements of the success of such a program are admittedly difficult. We recently-and inadvertently-had some measure of the success of our efforts. We, together with a similar public utility in Chicago, are cooperating through Northwestern cooperating Medical School, in a five-year national study of hypertension sponsoredThe the Department of Health, Department and Welfare. The other industry offers an annual examination to all employees. We, in contrast, have a
Arch Environ Health /vol 30, Aug 1975
health education program. As expected, the same number of hypertensives were found in both our employee populations. But, completely unexpected was the fact that twice as many of our employees were receiving optimum treatment as were those of the other public utility. Part of this certainly is due to our long-standing continued health education efforts. Again, contract physicians have evidenced little or no interest or expertise in the field of safety. Yet this is a legitimate-even necessarymedical department function. As the Occupational Safety and Health Act becomes more of an everyday reality in all of our lives, I suspect staff safety will become a medical department function. We have this responsibility now at Illinois Bell. Believe me, it is difficult to do from within the plant. I think it would be virtually impossible for a contract physicianother than one full-time to the plant premises-to conduct such a program. The contract physicians are much less likely to be able to give advice about the health effects of working conditions in a specific plant. Since their exposure is basically only to employees, and since they rarely have a chance to view the work situation at
first hand, their knowledge of each job is less. The in-plant physician is able to discuss working conditions with management, unions, and employees. Seeing the job conditions first hand is both easy and relevant. This also makes interpretations of government regulations and their impact on the industry much easier for the in-plant physician. I have tried to be objective-not argumentative; to be constructivenot destructive. I simply feel there are certain limitations of motivation, of time, of physical location, and of influence within the company that prevent the contract physician from being the "complete" occupational physician at the present time. However, in all fairness I must remind you that my remarks do not apply to the small plant in which more than 50% of all people work. The problem of health care for these employees can and will be solved only by contract physicians. While contract physicians today cannot offer a complete program, I can well visualize the time in the future where contract clinics, combining the resources of several or many industries, can and will conduct a full occupational medical program.
In-Plant Medical Services/Hilker
411
