Document 2mOZ9bOBd4mvv7Djrjjn8K65

NOTES ON DR. R. A. KEHQEfS DISCUSSION AT THE COMPANY MEDICAL MEETING ON THURSDAY, MAY 18, 1950 REGARDING THE CHANGING RESPONSIBILITY 0? THE INDUSTRIAL PHYSICIAN IN ENVIRON MENTAL HEALTH PROGRAMS I am particularly glad to have the opportunity to speak to this group, not only because I recognise many present, and have been associated with some, but because this represents an oppor tunity to speak with people who have approached their problems and responsibilities thoughtfully. No one can look at the rapidly shifting scene in the modern world without having some real concern as to its direction and its meaning. At this time, we are to consider not m e w orId but only the smaller area of modern medicine, and the still more limited area of industrial medicine. Even in this small bit of the modern world, it is important, if difficult, to find out where we aregoing and now we may proceed without losing the best of our professional discipline, virtue and integrity because of trends against which, at times we seem powerless. American society lias been characterized in the past by its considerable proportion of outstanding, competent individuals who have not feared or neglected to express themselves, who N9786 2. have grovn with their responsibilities, and who have undertaken to maintain their independence of thought and their integrity of purpose despite the progressive, and lately accelerated, drift toward domination of the life of our community by governmental and ^* pressure groups. I think our greatest present problem as a people is that of nurturing individuals of stature, courage and independence, against the powerful current which drifts toward uniformity and complacent mediocrity. If this is not done, the result will be the complete subjugation' of the individual by the mass or by its^vocal, irresponsible and self-serving leaders. That would be the end of American civilization as we have thought- of it. in.the past. In t*he fields of medical teaching, research and practice its> effects . would be no more disastrous than-in many others, and they might even be less so, but they would be serious iH \ v ?. ' In speaking of the physician in industry and of his changing situation, let us first.consider preventive medicine in industry - what it is in terms that we can understand - and then try to crystal lize an expression of viewpoint concerning it-w The application of `f lit* preventive medicine in industry is, first of all, a means of I determining the)jhealth -statw of 't\kJ industrial population. e carry out examinations of personnel and speak of them as preemploy ment or preplacement examinations. We also perform a series of examinations which come later, after the employee had teen put to work, leaving out of consideration for the moment any specific type of examination. The examination of personnel by'carefully selected, proper methods, and the adaptation of those met.ho`ds, as requir'eN\d, to everyone from top executives to hack gate keepers, can give us an overall understanding of the health status of the people for whom we are responsible, initially and as they continue to do the day's work. All critical medical examinations, by all appropriate *>. . ' ' methods Jaid the community toward this end. In tills way we are attempting to assess the hygienic status of the working population v 'V \ `\\ s. \ refit comes to us and continues under our supervision. This will " *:\ but of -\ be>the biggest function^ of the industrial physician of the future. / V co l CO CO We are interested in knowing something about the CO o o \ .. i efficiency of people in their work. The effectiveness of production V \\ w in industry is important to the community. It is the basis of our 4 in terms of both health and productivity. We are not attempting to select A-l employees only. We have the problem of employing our entire community in productive work, since to the extent that people are unemployed they are carried on our backs as a burden. It is a function of industry to employ all people and to find for them suitable employment from which they will earn their livelihood and in which they can combine their efforts in effective production. This is an important consideration. It applies to the top executive and down the line to the lowliest unskilled laborer. The periodic medical examination is something I am glad to discuss with medical men. We talk a great, deal about it without being convinced, collectively, that an annual health examination, at the hands of one's own physician, is a good or necessary thing. Most people do not believe in it very strongly. A large proportion of their doctors do not believe in it. ^he latter believe in taking care of the sick - the .people who come to them because they need help. They consider, rightly, that their first duty is to those who are in distress and not to those who fear that they may be, but they are also uncertain as to the merits and objectives of the 5* procedure. In contrast to this uncertainty, the periodic examina tion in industry does not have vague and indefinite objectives, since ve must, If possible, find means of fitting the individual to a job, finding out his degree of effectiveness individually and as part of a group, studying the effects of the stresses and hazards of his job upon him, and doing something about these situations as ve learn the facts. These may seem "high-sounding," but I vonder If ve cannot accept them as proper objectives. Why else should ve ' carry out these physical examinations if not for the purpose of obtaining information vith vhich to assess the status of men and groups of men in relation to the conditions under vhich they vorlc. inch's?#-* . To do these things ve must maintain adequate records and study them to find out the characteristics of the industrial population in terms of its health and effectiveness. We can learn by such means the significance of non-disabling and non-occupatlonal diseases. I am talking of the assessment of non-disabling and non-occupational diseases vhich interfere vith efficiency. His is an important point for consideration. Lost time from non-occupational diseases Is greater, according to statistics, than from occupational diseases. That this i3 true In the overall picture, I do not doubt, 6 although the statistics are probably somewhat distorted. However# the facts and their significance can better be established from the data of our examinations# when they become sufficiently precise and comprehensive. Certain other obvious types of information also can be obtained. v ., We are also seriously concerned about matters of public health# for example# the problem of the increasing incidence of the diseases of middle and later life, the so-called degenerative diseases. They seem to be increasing and moving into the lower age groups, ^ome groups are effected but others are not. There is no place in the American community in which these problems can be studied as effectively as in the working population. By means of competent, satisfactory medical examinations, and by the accumulation and utilization of such data, the health of our community can be interpreted. It is not too early in this discussion to point out that the working population is the largest segment of our entire population. What happens to the working population happens to the health of the nation. I feel strongly that we, as industrial physicians, have not fully realized in our working program the K 0 0 0 3 8 70 7 this work is begun, unless it is carried out by the medical repre sentatives of American industry, ve shall never have the time to do it. This requires good physicians - many of them. Ve shall not comprehend the situation unless the kind of medical work I am speaking about is supported by industry. At the present time the employees in small plants who have no medical supervision represent sixty.per cent or more of the industrial population. We shall have to find some means of extending industrial hygiene and preventive medicine to them. Large industrial organizations are attempting ( increasingly to do a good job in the medical field. They are few. They will have to be the pioneers who set the pattern for the larger undertaking. , SiTtH'av| t~j /,g ^ _ _ , .. ,, Hr?* af- f v*****^ During the past quarter of a century of my experience, industrial medicine has improved tremendously, but we medical men must realize we are just breaking ground in the field of industrial health. The recognition of specific occupational hazards is important, It is our primary job. Second in importance I think is the broader recognition of favorable and unfavorable occupational conditions. This is the problem of preventive medicine in industry. Chemical T98000 3 X 8 ones. It is fair to say that the industrial surgeons have the simpler jots. I do not wish to depreciate the contributions of the surgeons, but the more serious hazards derive from toxic materials and from physical agents which do not lend themselves to complete description, as for example, radioactive materials. Are these hazards recognized? he place to look for injured men is not in the dispensary but in the places in which they work. It is important to understand the hazards to which theworker-s are exposed and the effects of exposure to those hazards. If one is to acquire such understanding, he must watch men at work, lie must know the conditions under which they work and how such conditions are created. Ihis cannot be done by walking through a plant occasionally. One must stop and lock around to see how and why things are done. A plant survey from a medical standpoint is not simple. It requires observation, familiarity with people, familiarity with their points of view, and familiarity with what co CO they do. Everyone in the medical organization should know the problems of the plant, net only in relationship to diagnosis and the .interpre tation of occupational hazards, but in order to deal intelligently and properly with the men. It takes time to do this. Such knowledge 0008 and assessing all operating facilities and their maintenance; inspecting vashrooms and shover rooms and eating places - considering their comfort, cleanliness and convenience. If the plant lias a restaurant, the manner in which the food is handled and served should he observed. All too frequently in our work, we get too much involved in certain routines, such as preplacement examinations and periodic examinations which are part of our usual activities, instead of being concerned with the life of the plant in which people are at work. This can be done by observation of the men at vox`k and by the measure ment, where possible, of environmental factors with inspect to light, noise, temperatures,, chemical contamination of atmosphere and so forth. Here we bring into service and coordinate our thinking with that of the industrial hygiene engineer who has the training and facilities for carrying cut the determination of atmospheric conditions. I would like to stress tills point; In our medical the activities we cannot know too much about the work of/Industrial hygiene engineer. We are not concerned enough with what he is doing in order to make the best interpretation and use of his efforts. Hor is the industrial hygiene engineer sufficiently familiar with our work and needs and our ability to helip him interpret his work. In connection IO '# make observations, one never deals wholly with an engineering problem and never wholly with a medical problem, but with the combination of medical, physiological and technical problems. The physician and the physiologist must create the specifications for/good environment, If we physicians turn over to the industrial hygiene engineer the whole responsibility for physiological considerations, then we have forfeited our opportunities. * c-<a.* Accidents, illnesses and occupational diseases represent failures in our preventive program and they should be diminished to the vanishing point. From time -to time In ti-e3cper4mentalr-f-ie4d we ' V C iff * ! / are ssei concerned with the study of certain occupational d i s e a s e s ^ ' tncii iS-i'-C'y t**~>t&*e* isi/fSfa&ttcf!(lit&c.aJ ^`S ut*'!*-*/**-7^u..j y would--like- Lo ~ETtudy t5"'dlgeaue in tlieirr -were-t--maifes4at4eRe. Our aim^should be tb prevent the diseases by every oosnible'means. As pointed A */ out previously,. occupational hazards can be eeen.by watching the men at ' work, by the measurement of environmental factors and by clinical t 3 f Ou&j leoa/rt^v./ study of the men themselves^) 3ff--wo aro-to-be---regarded-as spoe-lallstB A'f 0008874 ,i n -the field of InriUaa-trJal.heal th , .Jwo.-o4auld~bo- the- Ju^yu^tLc <-$ t t-11 physicians in oarry-ing~out~ the-vepcd f1c d liffgirinatio ^p^eeedureor /St$L*. L jCL$.CAM.Qt^( UC^,-ti-> it'7^ t?tt ~$JC ki a _______ _ -- W"oWuia~^qHogn.isuo-- t . Us-v^ 0c**f5$~"fejfcd >3 bj *~f-*ft . - ' ^ y*i/i**-y&+****+ &. n. ./ >L. It 19 not tbe function of the Industrial physician,\by his clinical efforts, to ward off the inevitable effects of occupational conditions vhich are unsatisfactory* His function is that of recog nlzing such conditions and bringing them forcefully to the attention t of the responsible person or persons. Where there are unfavorable conditions,/he should make clear their existence and their effects. The approach should not be of a palliative character. -I have-w orked * t-"^xe problem of industrial lead 'it it j j h / CJLt,j[tsK%s/} -itP ^ f o g M aariy yea r s ,a s yer- iv-wJtr+S' < te&it unf 2pc Cu ->-G-t^ j know-. The information that is available at the present time should I enable us to eliminate lead poisoning from American industry, except a ** v. / in tho lUtl****t P y ,*.1^ (Mi/ a1ftuat-i-oaa. However, this has not been accom- -| plished. f^rviT]pJafv-^ri!ng to statistics,, the number of cases is . $ .' decreasing, the improvement is more apparent than real. The reason 3 for this, in many cases, is that management does not know the problem.^/ and has never been properly informed of it by physicians.^ti many industries the medical advisors do not understand the problem and are CO engaged in carrying out a palliative type of program. This is true m o ^ f jw *KA.Ua. t4j i.e'5*-**'****/ " o in -many.,of tho ot-uoru-t^ad^y anf particularly lu Lliosts longjestablished. o Vu k: When there is danger from a new chamical there is much more concern, but many of the familiar dangers from old chemicals are ignored. 12. J**y*'>i We find frequent reason to complain because Our doctor friends in the general practice of medicine make diagnoses of occupational diseases without knowing anything about industry. They often make the- diagnoses\cfit a patient's statement. As a rule, physicians in general practice do not know how to get from an industrial worker the proper information regarding his occupation* a- i J O i Aftan .pniinri.. ant a? a ,H a ',a compensation claim atfy is made because of a snap diagnosis -made-H^ 1the /'process of elimination. The -tga^-lcr-tlmt wo-ii>--Indusfepy-^ h o u - M /develop in-plant procedures . / . ~&Ev ' ' ' -*/ ' whereby 6. see the large proportion of all illness'y occupational and non-occupational, among employees. If there is any question of the differentiation of occupational from non-occupational disease or injury, w4 should be able to make it .Jer should get all the evidence y C ey obtainable. 3jbi can then make *itr own diagnoses and can see to it that all victims of occupational diseasy obtain what is coming to them in the way of care and compensation./ Mnnagirnirinfr-triuirit m w thr Maj^emenL^nnnt^^Iop^i^^JLghb^poli.sxiifesuiJaMming-- , the-faots-. <gfaay t ^thrust upon them. '^In-my*^penienc^^ewev'-er^>the^latter",'lB^,iTcrt 15 adequacy of our medical facilities for the care of our people and the value of our diagnostic facilities. In that way ve gain a respectful hearing from management andljfrom our medical colleagues in private practice. The industrial physician who is respected hy his colleagues in his community will have cases discussed with him. J .* J*- . ng~* o+'--Jav, learning not to make diagnoses without obtaining information from industrial physicians or other sources in plants about occupational conditions and hazards. The physicians in industry should work with the specialists in the community to be sure the right diagnosis is made. It is important to be in on the groundfloor and to be consulted before an opinion has been arrived a t . If a physician in general practice makes a diagnosis and places it on record, it Is hard for him to retract whether in court or for the record. If you can consult with him before he arrives at a conclusion, you may save much embarrassment and controversy. With regard to the recognition of unfavorable factors of industrial origin in the environment of a community, I need only mention the present interest in the general problem of water pollution and, still more recently, the problem of air pollution. The medical 14 point of view should be expressed in relation to the activities of Industrial plants which affect the community around them- Doctors should advise industry of the significance of water and air pollution, at least from their point of view. This aspect of preventive medicine in industry relates to hazards to the community as a whole. Industry should be aware of all the unfavorable conditions which it helps to create- These may become matters of ill-will and bad public relations, as well as financial and legal liabilities of significant proportions. Another point for consideration is industrial medical prac tice in relation to non-Industrial professional work. Satisfactory professional associations raust be cultivated by the industrial phy sician. The respect in which he is held by his colleagues will be based on his special skill and by his proper conduct of his medical work. He should exercise care to demonstrate that he is not trying to engage in private medical practice. Some think industrial medicine oo \ *>* c.o is a way to obtain private patients. On the contrary, the proper pro GO o Q cedure is to see to it that patients consult their own doctors and \ . O ;\ lu are responsive to their instructions. To maintain the proper rela V. tionships the industrial physician must belong to local medical organi 15 of the medical community. As to whether occupational medicine should be a recognized and certified specialty, it seems likely that this will come about advantageously in due course. Before we are ready for this we must define what we mean by the specialty of industrial medicine. I am not sure that we are able to set up such definitions on a broad base. What I may mean is one thing; what someone else thinks is another thing. Eventually, however, when the means of providing for adequate training in the specialty have been developed, /i-/Hu'e this natter will be ci^te-bified . At such a time the creation of a specialty board may well be desirable. I believe such boards have exercised an important influence on American medicine. However, lest we come to feel that such a board is necessary to the professional prestige of the industrial physician, it nay be worth while to note the existence of a special board for the man in the field of general practice - for the man who specialises in not being a specialist. Are we reducing professional specialisation to an absurdity? Another, and more significant point for consideration is the organisational status of the physician in industry - hia relationship to the industrial organisation. This i3 an important matter which we should define clearly for ourselves. I think it is fair to say that 0008679 16. ' "P the scope of the medical program and the medical policies of industry have "been made not by professional men but by industrial management. The usual procedure is for industrial management to decide what it wants. 7 rankly. I do not think it knows what it wants or needs in the medical and hygienic field of Its operations. The industrial physician himself should set the specifications on the nature the qualifications, and the work cf the industrial physician. He should accept er.plcynent In industry only if he can accept it on appropriate professional terms. If he cannot do so he should not engage in industrial medical practice. In short. industrial medical practice should be defined by the industrial physician and net by industrial management. I realize that the medical group in the Jersey company and its group of companies has bad great professional freedom to define the medical activities and policies. T M s is not the prevalent situation in American industry. In some companies there are good c.o CO relationships in some locations,but not in others. In situations co o involving a number of units in a big organization I believe in the Ui hp development of policy at the top, - not a policy which follows slavishly in the pattern of line organization, but one which is a 17* ( enS tOuuA^OS-&-C&J vufTu>-c4. -------------' -\ * professional people we are not working for each other| nevertheless, a medical policy can he established at an high level and carried out throughout an industrial organisation, lledieal men should always he able to bring their problems to an organisational level at which they will be given effective attention. I believe we shall never achieve satisfactory results in industrial organisations, with regard to the competence of medical people, their training, their willingness to empress themselves professionally, unless top medical men can always speak to responsible authorities when it is necessary to do so. I which do not believe in organizations in/the work of a physician is directed, for example, by the personnel manager of a plant. The medical man in industry, if he has the proper responsibility, must also have the proper authority. He must be able to talk to top management. No one in industry is in a position to make medical policy but a medical man. No one is in the position to set up the mechanisms whereby medical OQ CO opinion is implemented in relation to the changing social order and CO o o o general health cf the group and community but the physicians themselves. l-u X Ne must be able to provide capable people who know their work in the field of occupational medicine and can assume responsibility, and then 18. ; mean that medical men should he encouraged in authoritarian or arbitralmanage mveienwts cainrdc-laecst.s,-Tbhuets'ettraeemjarrnkhsoumldayhenoatblhee tpoermtaikneenttheomrsenlevceeesssha-er-ayrdinin connection with this organization. I do not presume to understand, all the ramifications of this company and its subsidiaries, but I do know that there are competent medical men in industry today whose judgments are being effectively barred because they Q not Peach the right people. One of the functions of the physicians in industry is to advise management in matters of health, e-en those that come o a-otfe., ht-U-i"s within the scope of collective bargaining^a& re-fork e d o health. hen A j.ndustry gets into situations in which medical and hygienic factors are matters of collective bargaining, the medical man.is in the middle. I do not think he can brook a situation in which policies of that type are made and bargaining carried out without his being consulted. He must decide those things which, from a medical point of view, can be bargained about and those which cannot be bargained about. In connection with differentiating between occupational and non-occupational diseases, there is real danger that the physician representing the labor union in a narrow sense, will be empowered with the right to review the case with the physician responsible, in an equally narrow sense, to industry-Uiader such conditions like 19 lawyers, each doctor will take sides. The only alternative is the achievement of a professional position, on the part of Industrial physicians, whereby it cones to be recognised, regardless of the source of their compensation, that they, have only one primary concern, that is, the health of the people. The medical man must maintain. ^against all~p^ssire^his professional position in complete integrity^ .n such a manner that those under his care can trust him implicitly. The evidence that, this can be accomplished resides in the fact that it has been done from time to time under suitable circumstances. Management will have to be advised by physicians as to the proper relationship between the doctor and the industrial employee. Suppose one must decide whether a, man is eligible for promotion. Suppose one finds that such a man will endanger himself and his company if he is given the new position, what should be done? To CO GO CO provide for such situations, there may be understandings, agreements CO o o and general policies, but in professional ethics and under the law o Ux there is no difference between the responsibility of the industrial physician to his patient and that of the private physician to his patient. Unless the employee gives consent to the transmission of position as his colleague In general practice If the Industrial physician makes a recommendation concerning a particular person, fox* example, as to what 3hould to done regarding M s protection from an occupational hazard, such as by M s removal from his job, the laws '> commonly make r ,v 4ml ra,?,.. r e i r management a\ C, ignore* this mandate. These and other matters of professional authority may be subject to evolutionary change in response to changes i n .our society, but they serve to illustrate the point that t.he physician is now,and has long been,vested with certain duties and professional responsibilities which he may not delegate to others. He need net do so in fulfilling hi3 function In industry, and If he dees so in weak ness or ignorance, he has forfeited M s greatest usefulness to the Industrial organization. The significance of the medical facts, and the role of the physician, in the field of compensation medicine, have undergone and are still undergoing extensive changes. In these states in which we have had compensation for accidents but not for occupational diseases, legal means have been found for redefining accidents. Sometimes the legal "accidentn i3 actually an occupational disease. Compensation ^ 0008884 21. for occupational diseases and occupational injury has been extended to Include a series of so-called contributory factors. All this is an indication of trends in the courts, by which the legal Interpreta tion of occupational injuries and Illnesses Is made in such a manner as to provide relief for the economic distress of the workmen, whether of occupational or non-occupational origin. Increasingly, thought and procedure turn toward methods of improving the economic position and security of the workman. In at least five states partial reim bursement of the workman for loss of his earnings because of non occupational illness has been provided for by law. I am quite confident that unless Industry^develops programs for so doing, It will, be only a short time until we shall see the enactment of state legis lation whereby the cost of sickness and of the medical care of indus trial employees will become a charge upon industry. Industry, more and more, is engaged In the development of programs of sickness benefits. Under these plans, Industrial physicians will be called upon, directly or indirectly, to provide more and more medical care for the employee at the expense of the employer. By such means medical care will be spread over a large segment of the community. R E 0008885 22 In this situation medical statesmanship is needed. Industrial physicians must think for themselves and consider, with industrial management, the economics of this situation and its professional and social significance. Industrial medicine may veil be called upon to provide competent medical care for tha3T portion of the community vhich Is represented in Industry. This -jha-fprobably the only alterna tive to state medicine in this country. e should examine carefully, from the point of view of Industrial medicine, means for the effective spread of both curative and preventive medicine to the general popula tion. With proper attention to the preventive aspects of medicine, this can probably be done economically. Otherwise, by offering medical care to all^at the expense of the state,ve shall Invite economic and professional chaos. It will not do merely to take the position that we do not like state medicine or any of Its socialised alterna tives . We must develop a policy in medical practice xvhich will be a safeguard against state medicine for sometime to come. The extension of industrial medical practice may become the most potent means of adapting medical practice to the needs of the community in a nation which still believes in and operates on the principle of free enterprise. This possibility is worthy of consideration