When industry is the patient L.M. CATHCART, FCFP
What does a physician do when he receives a letter from a local industry inviting him to review its occupational health needs? What does he do when a manager invites the physician out for lunch to discuss in-plant health? How does a physician respond when a personnel manager asks for a proposal for an occupational health program, and estimate of the cost, including the retainer expected by the physician? This article will explain ways in which a physician may respond with valid advice on companies' occupational health needs. Physicians involved in occupational health find it an interesting, stimulating and remunerative change of pace from office practice. In the United Kingdom, occupational health is recognized as a specialty. In North America it is generally in the hands of physicians who are usually interested and capable but have highly variable experience and training. Family physicians and internists are generally most commonly involved. There are increasing numbers of fulltime physicians in occupational health although these are still much in the minority. Once involved in occupational health, the fascination grows.
Growing demand The demand for more full- and parttime trained occupational health physicians will increase in Canada, as industry becomes more aware of its legal obligations to provide a safe working place. This means more physicians in practice today will be approached to supply medical advice to industrial managers and care for their workers. If physicians are interested in training programs, there are several available in Canada. Among them is a proReprint requests to: Dr. L. M. Cathcart, head, department of family medicine, St. Michael's Hospital, 30 Bond St., Toronto, Ont. M5B 1W8
gram toward a diploma in occupational health, established 25 years ago at the University of Toronto. Both the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons have repeatedly endorsed the importance of health in the working place, as has the CMA.1 There are now in most of the industrialized world stiffer laws to compel employers to provide safe working places. It is still a fact that many industries regard health as a bit of a cost frill and at best a cost benefit. Physicians have a unique opportunity here in this field to practise preventive medicine among a relatively stable work force subjected to environmental hazards, both physical and emotional. The occupational health physician can identify and survey hazards by constantly monitoring risks within the individual companies. The workplace also provides many fine opportunities for research. A stable population can be screened from time to time for nonoccupationally related diseases such as glaucoma, hypertension or cervical cancer as part of a complete preventive medicine program. Occupational health, surprisingly enough, has not occupied much time and space in our curricula or our practices. Surprising because much of our patients' time is spent working - and becoming ill while working. Compensation laws and accident disability benefits have jolted companies into cost consideration. Technology, unionization and shift exposure have markedly enhanced the occupational medical needs of industry. Recently, compensation payment for degenerative diseases and mental health impairment make industry ever more cost vulnerable. It would be unfair to accuse companies of seeking to retain medical advisers because of liability costs alone. However, cost has spurred industry to retain physicians for preventive health care programs and hazard control.
The health of the patient in the work place has been recognized for as long as the history of medicine can record. Hippocrates wrote of lead poisoning, Galen started his career as a physician to the most hazardous gladiatorial school in Pergamon.2 Many physicians have referred to the hazards of mining, particularly metal mining; through the centuries the insatiable demand for iron, copper and lead has taken its toll on the workers involved. It wasn't until 1700 that the Italian physician, Bernardino Ramazzini, published his outstanding "De Morbis Artifactum Distriba" (the English translation followed in 1705). This is a particular treatise on the disease of tradesmen. It is a medical classic and outlines the occupations of the day, and their specific causal impact on health. This book has remained as a reference up to the 20th century.
When approached for advice If a physician is approached by a company representative for advice and to act on a retainer basis, he may respond with a six-point program: * Occupational health hazards and environmental risk factors. * Non-occupational "shift care * Staff health. * Pre-employment medical examinations. * Absenteeism. * Industrial labour medical relations. The physician could first tour the company's premises. He should note physical plant facilities, hazards, general work areas, lighting, noise levels, employee attitudes and stress and facilities for health. There may be problems of absenteeism, increased disability and sickness rates above norms. Finally, the physician should note union involvement with health and ask about executive and employee health programs. Following this tour, the physician is in a position to write a short, formal
CMA JOURNAL/MARCH 18, 1978/VOL. 118 713
brief on the occupational health care needs of the company. He/she will have specific suggestions. Attached to the brief would be an estimate of costs for service, particularly medical service. The brief need not be complicated. A straightforward two pages, with retainer information attached, is all that is necessary. Occupational hazards
Perhaps the only lectures received in medical school on industrial medicine were those to do with industrial hazards; chemicals, lead poisoning, etc. These lectures might have been boring, but they enable the physician in his plant inspection tour to pick up important aspects of occupational care, such as watching a worker using a lead ashtray he has fashioned with loving but toxic care. The physician can suggest a monitoring system to be followed by the nurse in the plant. Occupational health nurses are generally highly competent. When the physician is not present, although he may be in close communication, the nurse is in charge and provides ongoing care. To fulfil this function the nurse needs special training in industrial hygiene. The laws in industrial hygiene are changing constantly as is the technology; thus it is important that management fund short courses for the nurse in monitoring industrial hazards. A physician's recommendation for this carries considerable weight. Toxic levels of chemical or other environmental hazards such as noise cannot be tolerated by industry, by unions, or by management. Departments of labour dictate minimum acceptable toxic levels. Excellent literature on toxic agents is available from industrial accident prevention associations, compensation boards and some universities. The physician will be especially sensitive to such hazards on his plant tour, and he would be wise to seek short courses in industrial hygiene and occupational health to heighten awareness of health maintenance and hazards. These courses are available but scarce; North America is far behind the United Kingdom and northern Europe in academic occupational health programs. Pre-employment physical examination
Many companies require pre-employment physical examination, particularly for 'heavy industry and heavy physical labour. A pre-employment examination will establish whether the job is safe for the applicant: whether his/her physical and emotional condition can cope with the job on a long-term basis. Therefore, the pre-employment examination is not simply a certificate of health for the
A preliminary tour of the plant gives a physician the chance to note facilities, potential hazards, patterns in absenteeism and the availability of health programs.
moment. It is a crystal-ball judgement on the future. This examination may well constitute a medical approval for the job and for the sickness insurance benefits of that industry. Today, disability fringe benefits are a part of industry. Industry is therefore reluctant to hire those who will be easily disabled and thus a future cost liability upon the company. For example, those with a history of back injury, or back disability, would not be employed for lifting and torsion jobs. They are simply inviting injury and disability. Perhaps the prospective industrial physician looking at a plant will decide that the rapid turnover of staff obviates the need for a pre-employment screening physical examination. Conversely, the touring physician may make a note of suspiciously rapid staff turnover and ask why. Perhaps there are physical or emotional hazards that dictate a high rate of resignations or layoffs. The plant nurse can function as the occupational practice nurse, given some training in physical diagnosis. She can assume the responsibility of pre-employment screening, referring questionable cases to the physician. There is an increasing concern with psychologic stress in industry. If the prospective employee has a history of psychologic problems or would be a
714 CMA JOURNAL/MARCH 18, 1978/VOL. 118
psychologic risk in the job, this should be noted. Most nurses on site will treat nonoccupational illness during a shift; they send the employee on to the family physician or appropriate health resource. There is considerable cost saving when the employee can return to his job after minor therapy. Serious non-occupational health problems can be handled by close cooperation between the occupational health physician or nurse and the personal physician of the employee. These problems, however, should be referred out of the plant health centre. Absenteeism
Absenteeism is not a medical problem. It is generally a problem of illness that can be well substantiated by the employee. If the problem is behavioural it is an administrative one and is a concern of management not of the physician. Occupational health physicians must be scrupulously careful to avoid being entangled. They may be asked to give an opinion on high shortterm absenteeism, its legitimacy, and whether it has behavioural overtones. In doing so we must be abundantly aware of the implications and dangers of what may be a management-union argument.
Absenteeism is a major problem in industry today. Up to 10% of employ. ees may be absent on a given day in some industries. A replacement must be paid and trained to do the job on short notice. Therefore, two people are being paid for the same job on the absentee day. With training costs and extra pay, managers generally estimate the cost of each day of absenteeism as 2½ times that of the usual day's work. A physician may be asked to look at the absentee figures of the plant to determine whether anything can be done in cooperation with community physicians. Patterns of absenteeism are important. Everyone is familiar with the Friday-Monday-payday syndrome of the possibly alcoholic worker. What is not realized is the importance of specific patterns of absenteeism of each employee in any given year. For example, a 2-week block absence of an employee is usually due to a significant illness. Fourteen days' absence spread over the year, by the day, is a. much more significant pattern and supervisors may query its validity. It is difficult to imagine illnesses that will keep a worker off repeatedly for 1 day only, 14 times. Physicians' certificates of illness deeply concern management in industry. They are often retrospective and given at the request of the employee. These certificates often legitimize the absence, socially and financially, yet there may be no medical basis for the absence. Sometimes little or no data are given, and the employee will present a number of these slips in a year. The physician touring the plant may offer to contact the personal physician to see whether the illness pattern of the absent employee has special significance.
policymakers and the implementation level.5 The prospective industrial physician touring the plant, then, may suggest a health appraisal program, provided the company is large enough to undertake it. The physician must be prepared to keep in contact with the family physician so that his findings will be readily available. The examination is an adjunct to the personal physician.s continuing care. Labour-industrial-medical relations In some companies union influence on policy will be substantial, particularly where employee risk and wellbeing are concerned. The occupational health physician treads a fine line in satisfying the union of his stance toward the employee. He is often regarded as a management figure, paid by management as a cost-saving device to keep the employee on the job as long as possible. Management would rephrase this statement to say that they are underwriting the health maintenance program to assist employees to maintain the highest level of health. The physician maintains his credibility and ethical stance by considering employee health and safety only, without regard to management or union pressure. Grievances and disputes may occur. The physician now truly earns his pay! For example, the physician will be asked for advice on employee disability, the degree of disability and the amount of absenteeism entitlement. The physician's advice *may be at some variance with that of the attending physician or consultant involved in the care of the employee. If the disagreement is major there may be discussion with labour and management before it Staff and executive health is resolved. These cases can be difficult, Many larger companies can afford and the occupational health physician staff health programs. These programs must be confident enough of his medcan involve screening for health risks, ical opinion to render it, then stick by fitness programs and a variety of health it and maintain his credibility. He does awareness programs. So there may be not enter into the union or management ongoing programs in chronic diseases: decision process. examples are programs against smoking Hiring and firing are no longer the or to discover hypertension and dia- strict prerogative of management. betes. There may also be a periodic Unions will have a say in the matter, assessment of selected top level exec- and again the physician is often asked utives within the plant. However, these to give a medical opinion, a task that are the key personnel at high risk with- simulates a high-wire act. in the plant. Their stress level is high; Community physicians and consulthey tend to be driving personalities tants may give an employee more days with excessive ambition and energy and or weeks off the job than is necessary. are "workaholics". Periodic examina- Or they may send a worker back to tion will point out their risk factors. work prematurely, thereby risking furSurprisingly, executives are often prone ther injury. The occupational health to ignore their health for long periods physician must give his opinion with - they are just too busy. Selected some firmness. If the case reaches the middle-rank executives can also be union grievance stage, the physician examined. They are often even more must be prepared to give his point of prone to stress than upper management, view and the thinking leading up to it. caught as they are between the top Union officials are as reasonable and 716 CMA JOURNAL/MARCH 18, 1978/VOL. 118
intelligent as management. They may appear to be unpleasantly aggressive at times; this, however, is part of their job, and they do it well. Finally, confidentiality must be maintained within any plant health centre. Employees and executives must feel free to speak of their problems without the fear that what they say will be passed on to a higher level. Naturally, many people in the plant have medical conditions that are known to everyone involved with them, and this cannot be avoided. But such information must not come from the health centre; only advice on disability and general medical policy should be forthcoming, and management should be given no more. Physicians will be under some pressure to give out information about specific illness. This they should not do. The word "disability" is a good euphemism to use in place of providing the diagnosis. Payment and time At present, the payment suggested by many physicians is between $25 and $70 per in-plant hour. Telephone advice will consume some time, as will letters dictated from the private office of the physician. This time may be counted as in-plant time. Charges vary depending upon the scope and experience of the physician involved. If advice is related to labour relations, medical refereeing or arbitration, the payment may be higher. The physician should build in a 10% contingency allowance for unforeseen time and work requests. Another rule of thumb may be $1 per employee per month, depending on the time spent in the plant. That is, in a 400-employee plant, the retainer would be $400 per month. It would be very difficult to manage the occupational health of a company reasonably without onsite time of at least 1 hour per week for every 100 employees. Therefore, for the 400-employee plant, 4 hours per week is a minimum. For a 2500 person plant, 25 hours in plant per week may be necessary at something over $2000 per month guarantee. For larger plants, a full-time physician is often required, although this is not absolutely necessary. Much depends on employers' initial needs. Some managements insist on pre-employment examinations, others do not. Some want executive physical examinations, accident and prevention programs etc. These functions take much more time and a higher number of hours in plant or out, and justify a higher retamer. Naturally, industry will cheerfully accommodate those who would charge less. Payment and time vary 'widely by industry and region. Companies are willing to pay well for advice, and payment
AtromidmS* (clofi brate) to lower blood lipids safely and effectively Indications ATROMID-S is indicated where reduction of blood lipids is desirable; e.g., patients with hypercholesterolemia and/ or hypertriglyceridemia. Contraindlcations While teratogenic studies have not demonstrated any effect attributable to ATROMID-S, its use in nonpregnant women of childbearing age should only be undertaken in patients using strict birth control measures. If these patients then plan to become pregnant, the drug should be withdrawn several months before conception. The drug should not be given to lactating women. ATROMID-S is not recommended in children since, to date, an insufficient number of cases have been treated. ATROMID-S is not recommended for patients with impaired renal or hepatic function. Warning Caution should be exercised when anticoagulants are given in conjunction with ATROMID-S. The dosage of the anticoagulant should be reduced by one-third to one-half (depending on the individual case) to maintain the prothrombin time at the desired level to prevent bleeding complications. Frequent prothrombin determinations are advisable until it has been definitely determined that the levels have been stabilized. For PRECAUTIONS and ADVERSE REACTIONS, see scientific brochure. Dosage and Administration For adults only: One capsule (500 mg) four times daily. Availability No. 3243 Each capsule contains 500 mg clofibrate N.F. in bottles of 100 and 360. Further information, references, and scientific brochure available on request.
Ayerst ** * AYERST LABORATORIES, division of Ayerst, McKenna & Harrison Limited, Montreal, Canada Made in Canada by arrangement with IMPERIAL CHEMICAL INDUSTRIES LTD. .Regd.
is not subject to third-party arrangements. Therefore, the privacy of the company-physician-employee relationship is maintained. Many companies are motivated by the cost-benefits of health programs but may, in the early stages of medical care, reject what they consider to be frills. Some large companies are content to let nurses give most of the occupational care within the plant, with physician back-up. This works extremely well unless the company has inherent industrial hazards that go beyond the capacity of nursing. Industries such as steel and automotive producers will have heavy physician input, whereas light industry
- say retailing or communications does with much less physician and more nursing services on-site. A physician may warn the industry that good health care is expensive. Management becomes, in time, health-aware and educated to its obligation. References 1. Basic principles for ihe provision of occupational health services, Ottawa, Can Med Assoc, 1977 2. SIGERIsT H: On the history of medicine, New York, MD Pub, 1960, pp 48-52 3. Conference on occupational health, international perspectives, STOPPS 3, con, Toronto, May 2-3, 1977 4. CATHcART LM: A four-year study of executive health. J Occup Med 19: 354 1977 5. DUNN JP, COBB 5: Frequency of peptic ulcer among executives, craftsmen and foremen. J Occup Med 4: 403, 1962
Manufacturers of OTC preparations organize a symposium on self*care D.J.R. ROWE A certain atmosphere of wariness was in the air at Ottawa's National Library auditorium as representatives of most Canadian manufacturers of nonprescription medicines or over-the-counter drugs (OTCs) gathered with pharmacists, physicians, drug advertisers, consumer advocates and federal government officials for a symposium on self-care Feb. 22-23. The conference was organized by one of the groups with the strongest vested interest in OTCs - the Proprietary Association of Canada, whose members manufacture such products as ASA, cough syrups, antacids, laxatives and vitamins and minerals, many of which are sold in supermarkets and corner stores as well as pharmacies and drug stores. Understandably perhaps, since such a meeting has not been attempted before in Canada, proceedings were controlled in such a way that "incidents" could be avoided. Even questions from the audience were collected on cards and read out by the symposium chairman. If PAC organizers were worried about disruptive events, they had nothing to fear from the physicians present. Except for those MDs representing government regulatory bodies, physicians said little that was challenging. Government health officials and the other physicians endorsed the validity of self-care and self-medication in the treatment of symptoms, while underlining the importance of better drug information and more pharmacist involvement in conveying this information to the public. The matter of doctors' understanding of nonprescription drugs was only lightly touched on.
Papers generally were short on hard data, except for those from the (as usual) well-prepared businessmen, reflecting the view expressed by several speakers that there is a lack of reliable research in the field of self-care and self-medication. However, two papers - from a pharmacist and an RN delved into revealing studies of drug use and misuse among the aged, a consumer advocate asked for many improvements in labelling and packaging and a pharmacy college lecturer discussed, with illustrations, some of the more blatant examples of OTC drug advertising. It happened that these presentations were by the only four women speakers. In an opening statement, J. Donald Harper, president of the PAC, said: "It has been estimated that if only 5% of consumers now coping with symptoms through self-medication were to abandon the use of nonprescription drugs and seek medical attention, the patient load on primary care practitioners would initially double Federal Health Minister Monique Begin said that self-treatment for certain physical ailments is a fact of life but that the public must be properly informed on the use and potential hazards of OTCs. Dealing first with the dietary aspect of self-care, Dr. A.B. Morrison, assistant deputy minister in charge of the health protection branch, Department of National Health and Welfare, said that "efforts will be made to reduce the fat content of the diet by decreasing the fat content of processed meats. Discussions are also underway between (the department) and the Department of Consumer and Corporate Affairs on
CMA JOURNAL/MARCH 18, 1978/VOL. 118 719
What does a physician do when he receives a letter from a local industry inviting him to review its occupational health needs? What does he do when a manager invites the physician out for lunch to discuss in-plant health? How does a physician respond when a personnel manager asks for a proposal for an occupational health program, and estimate of the cost, including the retainer expected by the physician? This article will explain ways in which a physician may respond with valid advice on companies' occupational health needs. Physicians involved in occupational health find it an interesting, stimulating and remunerative change of pace from office practice. In the United Kingdom, occupational health is recognized as a specialty. In North America it is generally in the hands of physicians who are usually interested and capable but have highly variable experience and training. Family physicians and internists are generally most commonly involved. There are increasing numbers of fulltime physicians in occupational health although these are still much in the minority. Once involved in occupational health, the fascination grows.
Growing demand The demand for more full- and parttime trained occupational health physicians will increase in Canada, as industry becomes more aware of its legal obligations to provide a safe working place. This means more physicians in practice today will be approached to supply medical advice to industrial managers and care for their workers. If physicians are interested in training programs, there are several available in Canada. Among them is a proReprint requests to: Dr. L. M. Cathcart, head, department of family medicine, St. Michael's Hospital, 30 Bond St., Toronto, Ont. M5B 1W8
gram toward a diploma in occupational health, established 25 years ago at the University of Toronto. Both the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons have repeatedly endorsed the importance of health in the working place, as has the CMA.1 There are now in most of the industrialized world stiffer laws to compel employers to provide safe working places. It is still a fact that many industries regard health as a bit of a cost frill and at best a cost benefit. Physicians have a unique opportunity here in this field to practise preventive medicine among a relatively stable work force subjected to environmental hazards, both physical and emotional. The occupational health physician can identify and survey hazards by constantly monitoring risks within the individual companies. The workplace also provides many fine opportunities for research. A stable population can be screened from time to time for nonoccupationally related diseases such as glaucoma, hypertension or cervical cancer as part of a complete preventive medicine program. Occupational health, surprisingly enough, has not occupied much time and space in our curricula or our practices. Surprising because much of our patients' time is spent working - and becoming ill while working. Compensation laws and accident disability benefits have jolted companies into cost consideration. Technology, unionization and shift exposure have markedly enhanced the occupational medical needs of industry. Recently, compensation payment for degenerative diseases and mental health impairment make industry ever more cost vulnerable. It would be unfair to accuse companies of seeking to retain medical advisers because of liability costs alone. However, cost has spurred industry to retain physicians for preventive health care programs and hazard control.
The health of the patient in the work place has been recognized for as long as the history of medicine can record. Hippocrates wrote of lead poisoning, Galen started his career as a physician to the most hazardous gladiatorial school in Pergamon.2 Many physicians have referred to the hazards of mining, particularly metal mining; through the centuries the insatiable demand for iron, copper and lead has taken its toll on the workers involved. It wasn't until 1700 that the Italian physician, Bernardino Ramazzini, published his outstanding "De Morbis Artifactum Distriba" (the English translation followed in 1705). This is a particular treatise on the disease of tradesmen. It is a medical classic and outlines the occupations of the day, and their specific causal impact on health. This book has remained as a reference up to the 20th century.
When approached for advice If a physician is approached by a company representative for advice and to act on a retainer basis, he may respond with a six-point program: * Occupational health hazards and environmental risk factors. * Non-occupational "shift care * Staff health. * Pre-employment medical examinations. * Absenteeism. * Industrial labour medical relations. The physician could first tour the company's premises. He should note physical plant facilities, hazards, general work areas, lighting, noise levels, employee attitudes and stress and facilities for health. There may be problems of absenteeism, increased disability and sickness rates above norms. Finally, the physician should note union involvement with health and ask about executive and employee health programs. Following this tour, the physician is in a position to write a short, formal
CMA JOURNAL/MARCH 18, 1978/VOL. 118 713
brief on the occupational health care needs of the company. He/she will have specific suggestions. Attached to the brief would be an estimate of costs for service, particularly medical service. The brief need not be complicated. A straightforward two pages, with retainer information attached, is all that is necessary. Occupational hazards
Perhaps the only lectures received in medical school on industrial medicine were those to do with industrial hazards; chemicals, lead poisoning, etc. These lectures might have been boring, but they enable the physician in his plant inspection tour to pick up important aspects of occupational care, such as watching a worker using a lead ashtray he has fashioned with loving but toxic care. The physician can suggest a monitoring system to be followed by the nurse in the plant. Occupational health nurses are generally highly competent. When the physician is not present, although he may be in close communication, the nurse is in charge and provides ongoing care. To fulfil this function the nurse needs special training in industrial hygiene. The laws in industrial hygiene are changing constantly as is the technology; thus it is important that management fund short courses for the nurse in monitoring industrial hazards. A physician's recommendation for this carries considerable weight. Toxic levels of chemical or other environmental hazards such as noise cannot be tolerated by industry, by unions, or by management. Departments of labour dictate minimum acceptable toxic levels. Excellent literature on toxic agents is available from industrial accident prevention associations, compensation boards and some universities. The physician will be especially sensitive to such hazards on his plant tour, and he would be wise to seek short courses in industrial hygiene and occupational health to heighten awareness of health maintenance and hazards. These courses are available but scarce; North America is far behind the United Kingdom and northern Europe in academic occupational health programs. Pre-employment physical examination
Many companies require pre-employment physical examination, particularly for 'heavy industry and heavy physical labour. A pre-employment examination will establish whether the job is safe for the applicant: whether his/her physical and emotional condition can cope with the job on a long-term basis. Therefore, the pre-employment examination is not simply a certificate of health for the
A preliminary tour of the plant gives a physician the chance to note facilities, potential hazards, patterns in absenteeism and the availability of health programs.
moment. It is a crystal-ball judgement on the future. This examination may well constitute a medical approval for the job and for the sickness insurance benefits of that industry. Today, disability fringe benefits are a part of industry. Industry is therefore reluctant to hire those who will be easily disabled and thus a future cost liability upon the company. For example, those with a history of back injury, or back disability, would not be employed for lifting and torsion jobs. They are simply inviting injury and disability. Perhaps the prospective industrial physician looking at a plant will decide that the rapid turnover of staff obviates the need for a pre-employment screening physical examination. Conversely, the touring physician may make a note of suspiciously rapid staff turnover and ask why. Perhaps there are physical or emotional hazards that dictate a high rate of resignations or layoffs. The plant nurse can function as the occupational practice nurse, given some training in physical diagnosis. She can assume the responsibility of pre-employment screening, referring questionable cases to the physician. There is an increasing concern with psychologic stress in industry. If the prospective employee has a history of psychologic problems or would be a
714 CMA JOURNAL/MARCH 18, 1978/VOL. 118
psychologic risk in the job, this should be noted. Most nurses on site will treat nonoccupational illness during a shift; they send the employee on to the family physician or appropriate health resource. There is considerable cost saving when the employee can return to his job after minor therapy. Serious non-occupational health problems can be handled by close cooperation between the occupational health physician or nurse and the personal physician of the employee. These problems, however, should be referred out of the plant health centre. Absenteeism
Absenteeism is not a medical problem. It is generally a problem of illness that can be well substantiated by the employee. If the problem is behavioural it is an administrative one and is a concern of management not of the physician. Occupational health physicians must be scrupulously careful to avoid being entangled. They may be asked to give an opinion on high shortterm absenteeism, its legitimacy, and whether it has behavioural overtones. In doing so we must be abundantly aware of the implications and dangers of what may be a management-union argument.
Absenteeism is a major problem in industry today. Up to 10% of employ. ees may be absent on a given day in some industries. A replacement must be paid and trained to do the job on short notice. Therefore, two people are being paid for the same job on the absentee day. With training costs and extra pay, managers generally estimate the cost of each day of absenteeism as 2½ times that of the usual day's work. A physician may be asked to look at the absentee figures of the plant to determine whether anything can be done in cooperation with community physicians. Patterns of absenteeism are important. Everyone is familiar with the Friday-Monday-payday syndrome of the possibly alcoholic worker. What is not realized is the importance of specific patterns of absenteeism of each employee in any given year. For example, a 2-week block absence of an employee is usually due to a significant illness. Fourteen days' absence spread over the year, by the day, is a. much more significant pattern and supervisors may query its validity. It is difficult to imagine illnesses that will keep a worker off repeatedly for 1 day only, 14 times. Physicians' certificates of illness deeply concern management in industry. They are often retrospective and given at the request of the employee. These certificates often legitimize the absence, socially and financially, yet there may be no medical basis for the absence. Sometimes little or no data are given, and the employee will present a number of these slips in a year. The physician touring the plant may offer to contact the personal physician to see whether the illness pattern of the absent employee has special significance.
policymakers and the implementation level.5 The prospective industrial physician touring the plant, then, may suggest a health appraisal program, provided the company is large enough to undertake it. The physician must be prepared to keep in contact with the family physician so that his findings will be readily available. The examination is an adjunct to the personal physician.s continuing care. Labour-industrial-medical relations In some companies union influence on policy will be substantial, particularly where employee risk and wellbeing are concerned. The occupational health physician treads a fine line in satisfying the union of his stance toward the employee. He is often regarded as a management figure, paid by management as a cost-saving device to keep the employee on the job as long as possible. Management would rephrase this statement to say that they are underwriting the health maintenance program to assist employees to maintain the highest level of health. The physician maintains his credibility and ethical stance by considering employee health and safety only, without regard to management or union pressure. Grievances and disputes may occur. The physician now truly earns his pay! For example, the physician will be asked for advice on employee disability, the degree of disability and the amount of absenteeism entitlement. The physician's advice *may be at some variance with that of the attending physician or consultant involved in the care of the employee. If the disagreement is major there may be discussion with labour and management before it Staff and executive health is resolved. These cases can be difficult, Many larger companies can afford and the occupational health physician staff health programs. These programs must be confident enough of his medcan involve screening for health risks, ical opinion to render it, then stick by fitness programs and a variety of health it and maintain his credibility. He does awareness programs. So there may be not enter into the union or management ongoing programs in chronic diseases: decision process. examples are programs against smoking Hiring and firing are no longer the or to discover hypertension and dia- strict prerogative of management. betes. There may also be a periodic Unions will have a say in the matter, assessment of selected top level exec- and again the physician is often asked utives within the plant. However, these to give a medical opinion, a task that are the key personnel at high risk with- simulates a high-wire act. in the plant. Their stress level is high; Community physicians and consulthey tend to be driving personalities tants may give an employee more days with excessive ambition and energy and or weeks off the job than is necessary. are "workaholics". Periodic examina- Or they may send a worker back to tion will point out their risk factors. work prematurely, thereby risking furSurprisingly, executives are often prone ther injury. The occupational health to ignore their health for long periods physician must give his opinion with - they are just too busy. Selected some firmness. If the case reaches the middle-rank executives can also be union grievance stage, the physician examined. They are often even more must be prepared to give his point of prone to stress than upper management, view and the thinking leading up to it. caught as they are between the top Union officials are as reasonable and 716 CMA JOURNAL/MARCH 18, 1978/VOL. 118
intelligent as management. They may appear to be unpleasantly aggressive at times; this, however, is part of their job, and they do it well. Finally, confidentiality must be maintained within any plant health centre. Employees and executives must feel free to speak of their problems without the fear that what they say will be passed on to a higher level. Naturally, many people in the plant have medical conditions that are known to everyone involved with them, and this cannot be avoided. But such information must not come from the health centre; only advice on disability and general medical policy should be forthcoming, and management should be given no more. Physicians will be under some pressure to give out information about specific illness. This they should not do. The word "disability" is a good euphemism to use in place of providing the diagnosis. Payment and time At present, the payment suggested by many physicians is between $25 and $70 per in-plant hour. Telephone advice will consume some time, as will letters dictated from the private office of the physician. This time may be counted as in-plant time. Charges vary depending upon the scope and experience of the physician involved. If advice is related to labour relations, medical refereeing or arbitration, the payment may be higher. The physician should build in a 10% contingency allowance for unforeseen time and work requests. Another rule of thumb may be $1 per employee per month, depending on the time spent in the plant. That is, in a 400-employee plant, the retainer would be $400 per month. It would be very difficult to manage the occupational health of a company reasonably without onsite time of at least 1 hour per week for every 100 employees. Therefore, for the 400-employee plant, 4 hours per week is a minimum. For a 2500 person plant, 25 hours in plant per week may be necessary at something over $2000 per month guarantee. For larger plants, a full-time physician is often required, although this is not absolutely necessary. Much depends on employers' initial needs. Some managements insist on pre-employment examinations, others do not. Some want executive physical examinations, accident and prevention programs etc. These functions take much more time and a higher number of hours in plant or out, and justify a higher retamer. Naturally, industry will cheerfully accommodate those who would charge less. Payment and time vary 'widely by industry and region. Companies are willing to pay well for advice, and payment
AtromidmS* (clofi brate) to lower blood lipids safely and effectively Indications ATROMID-S is indicated where reduction of blood lipids is desirable; e.g., patients with hypercholesterolemia and/ or hypertriglyceridemia. Contraindlcations While teratogenic studies have not demonstrated any effect attributable to ATROMID-S, its use in nonpregnant women of childbearing age should only be undertaken in patients using strict birth control measures. If these patients then plan to become pregnant, the drug should be withdrawn several months before conception. The drug should not be given to lactating women. ATROMID-S is not recommended in children since, to date, an insufficient number of cases have been treated. ATROMID-S is not recommended for patients with impaired renal or hepatic function. Warning Caution should be exercised when anticoagulants are given in conjunction with ATROMID-S. The dosage of the anticoagulant should be reduced by one-third to one-half (depending on the individual case) to maintain the prothrombin time at the desired level to prevent bleeding complications. Frequent prothrombin determinations are advisable until it has been definitely determined that the levels have been stabilized. For PRECAUTIONS and ADVERSE REACTIONS, see scientific brochure. Dosage and Administration For adults only: One capsule (500 mg) four times daily. Availability No. 3243 Each capsule contains 500 mg clofibrate N.F. in bottles of 100 and 360. Further information, references, and scientific brochure available on request.
Ayerst ** * AYERST LABORATORIES, division of Ayerst, McKenna & Harrison Limited, Montreal, Canada Made in Canada by arrangement with IMPERIAL CHEMICAL INDUSTRIES LTD. .Regd.
is not subject to third-party arrangements. Therefore, the privacy of the company-physician-employee relationship is maintained. Many companies are motivated by the cost-benefits of health programs but may, in the early stages of medical care, reject what they consider to be frills. Some large companies are content to let nurses give most of the occupational care within the plant, with physician back-up. This works extremely well unless the company has inherent industrial hazards that go beyond the capacity of nursing. Industries such as steel and automotive producers will have heavy physician input, whereas light industry
- say retailing or communications does with much less physician and more nursing services on-site. A physician may warn the industry that good health care is expensive. Management becomes, in time, health-aware and educated to its obligation. References 1. Basic principles for ihe provision of occupational health services, Ottawa, Can Med Assoc, 1977 2. SIGERIsT H: On the history of medicine, New York, MD Pub, 1960, pp 48-52 3. Conference on occupational health, international perspectives, STOPPS 3, con, Toronto, May 2-3, 1977 4. CATHcART LM: A four-year study of executive health. J Occup Med 19: 354 1977 5. DUNN JP, COBB 5: Frequency of peptic ulcer among executives, craftsmen and foremen. J Occup Med 4: 403, 1962
Manufacturers of OTC preparations organize a symposium on self*care D.J.R. ROWE A certain atmosphere of wariness was in the air at Ottawa's National Library auditorium as representatives of most Canadian manufacturers of nonprescription medicines or over-the-counter drugs (OTCs) gathered with pharmacists, physicians, drug advertisers, consumer advocates and federal government officials for a symposium on self-care Feb. 22-23. The conference was organized by one of the groups with the strongest vested interest in OTCs - the Proprietary Association of Canada, whose members manufacture such products as ASA, cough syrups, antacids, laxatives and vitamins and minerals, many of which are sold in supermarkets and corner stores as well as pharmacies and drug stores. Understandably perhaps, since such a meeting has not been attempted before in Canada, proceedings were controlled in such a way that "incidents" could be avoided. Even questions from the audience were collected on cards and read out by the symposium chairman. If PAC organizers were worried about disruptive events, they had nothing to fear from the physicians present. Except for those MDs representing government regulatory bodies, physicians said little that was challenging. Government health officials and the other physicians endorsed the validity of self-care and self-medication in the treatment of symptoms, while underlining the importance of better drug information and more pharmacist involvement in conveying this information to the public. The matter of doctors' understanding of nonprescription drugs was only lightly touched on.
Papers generally were short on hard data, except for those from the (as usual) well-prepared businessmen, reflecting the view expressed by several speakers that there is a lack of reliable research in the field of self-care and self-medication. However, two papers - from a pharmacist and an RN delved into revealing studies of drug use and misuse among the aged, a consumer advocate asked for many improvements in labelling and packaging and a pharmacy college lecturer discussed, with illustrations, some of the more blatant examples of OTC drug advertising. It happened that these presentations were by the only four women speakers. In an opening statement, J. Donald Harper, president of the PAC, said: "It has been estimated that if only 5% of consumers now coping with symptoms through self-medication were to abandon the use of nonprescription drugs and seek medical attention, the patient load on primary care practitioners would initially double Federal Health Minister Monique Begin said that self-treatment for certain physical ailments is a fact of life but that the public must be properly informed on the use and potential hazards of OTCs. Dealing first with the dietary aspect of self-care, Dr. A.B. Morrison, assistant deputy minister in charge of the health protection branch, Department of National Health and Welfare, said that "efforts will be made to reduce the fat content of the diet by decreasing the fat content of processed meats. Discussions are also underway between (the department) and the Department of Consumer and Corporate Affairs on
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