Document 6B71mm1wp8DMoZ9eYNjJGEr5R

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" a W-- ^aStccfi as from a personal, individual viewpoint, it is perfectly clear that they art of equal impor tance to ail industry regardless of the indus try't size or nature. The most complete and systematic services naturally have been developed in larger, wellestablished industries. But such companies comprise only about 10 per cent of the nation's employers, and only one-fourth of its workers. The remaining three-fourths are employed in businesses too small to justify a full-time medi cal director. How, then, can smaller plants which employ the majority of the nation's workers obtain industrial health services? Service* for Small Plants It is sometimes possible to arrange with a group of physicians who are especially inter ested in industrial medicine to serve several industries. Hours and pay are usually prorated according to payroll. This plan has worked out satisfactorily in many places and it has many advantages* State and local medical societies usually have information about available plans of this type. For the most part, smaller industries rely first on the part-time services of a local physi cian. who should have certain qualifications, and second on the services of an industrial nurse, full-time if possible, but if not, on her part-time services. Part-time physicians in industry--In order to meet medicine's responsibilities in indus trial health, the local physician chosen for part-time service in industry must have four essential qualifications: First, of course, he must be a good doctor, a graduate of an accredited medical school, and he must be respected in the community. Second, be must understand and have an interest in problems peculiar to industry. This means keeping regular hours in the plant, see ing employees who want advice, inspecting work places, and watching for potential haz ards in new material*'and procedures, Jt means accepting the responsibility as a physician to act as mediator between labor and manage ment on health matters. It means willingness to learn new developments in industrial health by reading books and periodicals, and by at tending meetings devoted to the subject. The industry should assist the physician to attend such meetings. Third, the physician chosen must have a high sense of medical ethics and never use his industrial connections to build his private practice. He must respect and preserve exist ing good relationships between employees and their own doctors, and be able to work with physicians in the community as a respected colleague and consultant. Fourth, he must have such status within the company that he can make health recom mendations directly to top management. His medical and legal responsibilities alone make adequate status essential, but there are other considerations. The physician's position in the company indicates to workers the degree of importance management places in its health services. Also, physicians willing to devote time to industry are entitled to employee status which, as Newman* has pointed out, often gives them needed benefits of the company's retirement and disability plans. Nursing service in industry--A full-time or, if necessary, a part-time industrial nurse can be an invaluable aid to workers, to manage ment and to the industrial physician, but she. too, must meet certain requirements. The American Association of Industrial Nurses has available a list of recommended personal and professional qualifications for nurses in indus try, as well as a resume of recommended duties and responsibilities.9 An industrial nurse must be. first, a good nurse, a graduate of an accredited school of nursing. She must have a well-developed inter est in people and the ability to work with all types. She must have good judgment and be able to maintain a balance between her re sponsibilities to management and to the in dividual worker. Ready access to medical supervision is a necessity. Nurses working in sraaU ptants with out (ulUime medical supervision are some times aiked by employers and employees to ''treat illness and injury to an extent which is dangerous and often illegal. The worker and management as well as the nurse sre pro tected when the has a set of standing orders Aufutt 19SS 191 signed by the plant phyiician. The amount and kind of emergency care and treatment a nurse may give is dependent on a physician's legal order. Verbal instructions have no place where legal liability is a factor. Although part-time medical and nursing services may offer more problems than a com plete. full-time program, they can be adequate for the needs of small plants. Properly devel oped, they provide for management and work er the same essential protection afforded by the full-time programs of larger plants. The responsibilities of an industrial health team, regardless of the size or nature of the indus try it serves, sue: 1. To protect employee and employer alike from hazards arising from and in the course of employment. 2. To bring to the industry every known means in preventive and curative medicine which may improve the health of all the work ers, including management. 3. To adjust the health program to the over all objectives of the industry, with due regard for economy and efficiency, as well as the known health needs of the employees. 4. To advise both management and labor on all policies having a health aspect These range from job placement to the medical care included in fringe benefits. 5. To act as a bridge between the indus try and the community health and welfare agencies so that employees and their families may take full advantage of community facili ties available to them. Cost and Profit Management must naturally know two things about an industrial health program: What does it cost and what do we get? 1 have tried to explain what management gets. The cost will run from $5 to $30-plus per em ployee-year. depending on how complete the program is. The latter figure should provide almost complete medical and hospital care for the majority of illnesses. Most of the preven tive services mentioned can be provided on a S12 to 315 per employee per year budget. Whether such a program will pay for itself or even - save money, many physicians are loath to say. Some companies writing work men's compensation insurance can show a saving in claims that is more than enough to pay for the program. There is much that is intangible about health and medical service, as is true with all em ployer-employee relations. Very few- industries have discontinued a health program once it has been started. The benefits, both preventive and curative, should be self-evident. If greater profits result, as they can, they should be con sidered a fortunate by-product. Conclusion What medicine expects from a successful industrial health program is exactly what both management and labor want, too--healthier, happier, more productive workers, and a more prosperous industry. As more physicians and nurses develop the skills needed for effective industrial health services, and as more indus tries offer opportunities to use these skills, medicine's expectations--which we all share-- can become realities. serrxzNczs 1. In>ua. W. f. tail Aiaariinii LaaraiiaJa f rubU Health. XA. t. FWaJtfrhla. 1. S. Dppiarait C>ay, 1932. efcsp. I- 2. Mif, ftcwaaar Aaaaal wpm aa aaeapaJiaaal health am. (1. S. P*Mk Health StrriM la Cwc8 at Udoamal Health, la CaaatU MJaaiaa. Aatnui MariJc*) AaaatiaiMa, 19*4. L lapWfN health Nam M *aU plaaaa. la: Otrafaiioaal Hrshb Sanaa Kaabn fc. New Yak, Mairayalhaa DM lauriatt Can* W. WL 4. Naa. L. Li Vbai auaateaaaat abaaltf kaa* abaat iadn- trial bullk Iluigiaai Matbafc 7 JO-34 (March! IHL 3> laeaauaaaiid qaallltniaaa. Ha* Yarfc. Aiaetiua Auaciatiaa *< Motml Km*. Jaaa |9tt- ' -r* i in r-0TC*t *TC MtDICiMt < Cincinnati Journal of Medicine PobBskad ndat tha saspkM ai THE ACADEMY OF MEDICINE OF CINCINNATI INDUSTRIAL HEALTH --A CHALLENGE TO MEDICINE* William P. Sbetau, MJD.t I. Introduction I need hardly remind this audience that no physician can practice good medicine unmindful of his patient's occupation. Even the housewife encounters occupational hazards, as do the whitecoliar worker and the farmer. What I wish to speak of tonight is the health of the industrial worker, one of the nation's most valuable assets, and how his health protection may affect the practice of medicine in industrial areas like Cin cinnati. Urbanization and industrialization are having profound effects on die practice of medicine. Thousands of young families are moving into industrial centers, leaving behind the stabilization of family ties, including the family doctor. In dustry's ever-changing processes are inevitably accompanied by ever-changing health and safety hazards. Industry provides a unique environ ment in which to accomplish the modern physi cian's objective of combining preventive medicine with therapeutic medicine. Only physicians can supply the skill and knowledge needed to minimize the physical and mental attrition inherent in work, and in living in general. Our national economy can no longer afford the old practice of limiting the privilege of work to those most nearly physically perfect. Em ployers nowadays are gradually accepting the con cept that some kind of job can be found for nearly everyone. To do so, however, requires the best -^ - PrM&t*d baler* th# QaAtauit Arade7 of Mtdldw, 'Apcti I, ItSi. t$*saad Vtc*-pT*datrt. Matropelrtaa UJ* Iwura&c* Company) Chairman, Cransli an Industrial Hralth. Amanera Midied Aiwootwa. of medical appraisal of physical and mental endow ments. The work place, be it large or small, offers the physician unparalleled opportunities to match the demands of the job with these endowments. More than three-fourths of the workers and nine-tenths of the employers of. this country are in establishments too small to justify engaging a full-time medical director.1 Whatever occupa tional medical guidance they get must come from pan-time physicians who have some interest and competence in the health problems of industry. IL The Scope of Industrial Medicine The scope of industrial medicine is wide, but there is a core of essential service equally im portant to all industries, large and small3 They may be outlined limply as follows: A. Control or tbs Environment such as-- (1) Toxic kaxardt-- dusts, lead, beryllium, carcinogens, and many others. Such hazards are relatively rare but of peat importance to industry because of their preventability and com pensability. (2) Air, Light, Temperature, Sound-- including safeguards against excessive noise, extremes of barometric pressure, temperature and humidity, defective light ing, and exposure to radiant energy. (3) Injection*-- ranging from the baffling proofed of the common cold to tuberculosis, apthrax, and 'brucellosis, t " ' v (4) Accidentt-- the general field of environmental con trol also includes medical co-operation j) Reprinted from the Cincinnati Journal of Medicine, s 37:45-48,1956 46 iNoumuL Health CtNClNNATt JOUtNAL OP MEDICINE, FESXUABY. 1956 with the safety engineer, since a large proportion of accidents have a psychologi cal etiology and are therefore in the medical field. B. Job Placement Management cannot make the most of the available supply of manpower without the medical guidance provided by the preplace ment examination. Its purpose is to assay the physical and mental assets and liabilities of the individual so that medical recommenda tions can be made as to the kind of jobs he is best fitted for. In order to do this the physi cian must know the demands of the various jobs in the industry. It is therefore important for him to make rounds in the plant frequently enough to observe the physical and mental stresses and the potential hazards involved in each job. Job placement is a cooperative enterprise in which management has the final decision, but in which wise management will give full consideration to the physician's recommendations. C. Health Maintenance Once management has its quota of employees, it has a considerable investment in them. It makes good sense to protect that investment Only the physician or his personally trained and supervised representative (nurse or other inspector) can detect through periodic in spections, bad practices which may increase toxic or accident hazards, improper sanitary facilities, and potential hazards to the water, food, and milk supply. One of the most important instruments of health maintenance is the periodic health exam ination of employees.' The technique and com prehensiveness of this examination are best determined by the physician. They will depend upon the hazards to which the employee is exposed, his age, his medical history since the preceding examination, and a renew of his physical defects. Oftentimes incipient degen erative disease can be detected in its earlier and more treatable stage. Frequently medical advice can be given about habits of work, recreation, and rest which will avoid or post pone disability. Many times the industrial physician is able to detect beginning serious condition^ which call for careful medical attention. His usual pro cedure then is to urge the employee to seel? advice of his own personal physician. The industrial physician has a natural interest in and responsibility for follow-up of em ployees who^lre under the care of their pri vate physifJjn. He is usually a welcome con- sultant over the telephone or otherwise when he inquires of the health of an employee. He is frequently able to assist with the employee's rehabilitation by arranging a modification of duties upon his first return. There are many elaborations of these essential services which need not be detailed here. Some industries have arrangements for hospital care, some of them owning and operating their own hospitals. All industries in the United States are required to give complete medical care for workmen's compensation cases. Some union health centers provide out-patient care only and have some type of insurance coverage for hospital care. x D. Oveb-All Pictltie If we take a long view of medicine in industry, we will see a number of things happening that are important to organized medicine in general, and particularly to the private practicing physician in any industrial area. First there is greater demand for medical service, guidance, and advice in industry than ever before. This is partly because more are employed than ever before. It is also because good medical programs in industry often re duce the cost of workmen's compensation in surance. Today management recognizes in creasingly the importance of morale among workers. Healthy, happy, willing workers may make the difference between profit and loss. A good medical program improves morale. Second, there is a great demand from unions for fringe benefits, including some form of medical care. Thus, the bargaining table has forced some employers to provide funds for medical care for their workers. Third, in some sections of the country a system of medical co-operatives has developed in which the physician or a group of physi cians is guaranteed a minimum income and adequate hospital and laboratory facilities by the employer and the community. Finally, there has been an enormous growth in the number of people who provide themselves voluntarily with some form of prepayment plan through which medical and hospital bills are paid either in full or inJBft- The Health Insurance Council estimates tttit ninety million ^individuals in this country are' now provided mth one omnother form of prepayment medi-" cal or hospital care.4 Enormous forces, sociological and political, are focusing attention on the purchase of medi cal care. Purchasers of medical care need our guidance as to quality, quantity, and cost. We must take every opportunity to advise them on VOL 87, No. 2 iN'oumuAL Health 47 how good medial are an best be provided. Ii we do not make our wees heard, we do a disservice to the public and to our profes sion. It remains to be seen whether the impact of present-day forces will result m a bilateral agreement between management and labor as to the kind, quantin', and cost of medial care to be provided. If so, medicine will be between the upper and nether millstones. Now is the time to strive for a tri-partite agreement among management, labor, and medicine. This will not come easy. The historv of govern mental control of medicine in Europe is not reassuring, nor is the history of the workmen's compensation acts of the various states of this country. In both instances medial advice was largely ignored during the legislative stages. These are matters of concern and of action in the Amerian .Medial Association. Their Council on Industrial Health has for many years studied health problems in industry and their relationship to the private practice of medicine. For fifteen vars it has held its annual Congress on Industrial Health at which Iraders oi medicine, management, and labor are heard.6 The board of trustees of the AMA has recently appointed a commission to make a complete study of all forms of prepayment medical are and to report to the board of trustees within the year.' HL The Job To Be Done and How To Do It From this brief description of the scope of industrial medicine, and of the over-ait picture, let us now turn to the job to be done and bow to do it. We have just considered the need for immedi ate medial leadership. This can best be asserted in the local communities, because the national organizations, including the Amerian Medical Association, are only the Sower oi the organiza tion "plant" whose roots come from each local community. One of the most helpful things that can be done to assert medial leadership is the appoint ment of a committee on occupational health by each state medical society and each local society where there is any amount of industry. The Council on Industriid Health has been advoating this practice for years, and now some thirty-eight state societies have such committees. Once a year their representatives meet at the annual Congress on Industrial Health, where we devote an entire day to the discussiotf of local problems. These committees receiveHtudies and other publiations of the Council/ Through correspondence, and, when necessary, personal visits, special attention is given by our staff to problems which they wish to present. Such committees study the special needs and health problems of local industries, and develop channels of communication through which medial advice and assistance can be readily obtained. The second job to be done is to devote our attention to the preparation of more physicians to serve industry on a full-time basis. This is much' easier than formerly. Several excellent one to three-year courses have been organized in public health schools and in graduate medio) schools, where physicians may obtain the best of training. Thanks to the devoted efforts of a few who are pre-eminent in the specialty of industrial medicine, an Interim Specialty Board has been formed and has drawn up a plan for accrediting these courses and for providing suitable residencies for those who wish to specialize in this- held. These plans have been approved by the Council on Medical Eduation and Hospitals of the AMA, and by the .American Board of Preventive Medicine, which is now ready to begin to examine and certify, as specialists, physicians who demonstrate special qualifiations in this field. The third job is to encourage pbysidans to become interested in part-time work in industry. As we have seen, the)- must provide the industrial medical are for the gTeat majority of workers in this countn* who are in plants too small to justify a full-time medial director. A long post-gaduate course of specialist training is not essential to these men. They may leant much by attending the several short courses now available, by reading the several excellent periodials devoted to the subject of industrial medicine, and by attending the several scientific meetings devoted to occupa tional health. These men may be considered the general practitioners of industrial medicine. Like other general practitioners, they will know when to call in the industrial medial specialist when they encounter special problems beyond their competence. A fourth job is to make it keXCn to loal industry, ^jjat the aunty *mtdial society and a -- group of specially imerested physicians are avail able to them for advice on specific health problems, and for assistance in looting part-time medial consultants when they are ready to do so. A possible fifth job has been undertaken in some cities where a group of physicians with <8 Injujstxul Health CixaNriATi Jouxmal or Medicine, Fehuabt, 1956 special competence in the industrial field has organised to serve small industries on a unitservice basis. In such plans a member of the staff goes to each of the subscribing industries, for whatever length of time seems necessary each week, to give the basic medical services which every industry so urgently needs. The service is paid for on a formula based on the size of the pay roll of the industry.* Finally, among the tasks to be done is for all physicians, general practitioners and specialists alike, practicing in an industrial community, to acquire at least a general knowledge of the prob lems of occupational medicine and an understand ing of the functions and purposes of the industrial medical director. They will come to regard the medical man in industry as a valued consultant and colleague who is not encroaching on the private practice of medicine, but rather enhancing it, and who will be helpful to the patient when the time comes for his return to work. AH physicians must bear in mind that the doctor's report on the degree and length of disability of his patient is accepted by industry and by the insurer alike, as prima fade evidence. It is seldom questioned. Every physician who signs a claim paper of any kind for an industry or an insurance company, including Blue Cross and Blue Shield, will re member what was so pointedly stated by one of the medical speakers at the last industrial health congress, "The doctor can make or break any prepayment medical plan." Accomplishment* Which May Be Expected When all this is done, and it will take time and patience to do it, what then may are expect to have accomplished? Occupational medicine is a challenge to the medical profession, both scientifically and socio logically. It presents many curious phenomena, many problems which are basically toxicological or chemical in nature, many of which are solved only by a thorough knowledge of normal anatomy and physiology, many problems of psychosomatic medicine. To have the opportunity to study these problems is interesting end exciting to many. Since production and military strength- go hand in hand, it is essential to the defense of the, nation to keep production at a maximum. Much of this is a medical problem, And thus physicians who are engaged in it are participating importantly in the nation's safety and preservation. The opportunities for research in industrial medicine are almost limitless. Here the physician may encounter his first opportunity to study health statistics in the mass, either of presumably well people or of those with known physical impair ments. One eminent surgeon's chief delight is the few hours a week he spends in a large industry where he now has complete records on over 2,000 cases of gastric and duodenal ulcer with exact records of what has happened to them for a mini mum of ten yean. How does the individual with cardiac impairment fare in industry? Does he rightfully belong among the unemployed,' or can he serve some useful purpose under proper medi cal guidance? What does the aging process do to the avenge worker? How sbon and at what point in his anatomy will the first signs of arterioscler osis appear, and how mud] of a handicap will it be? Industry offers an opportunity to keep exact records on die amount of disability from accident and illness in a group of working people, and the effects of various methods.' of reducing this ab senteeism. Industry offers Almost as much oppor tunity as does a school for various techniques of health education and their evaluation. Conclusion It would seem that the proper place of the physician in the cosmos of industry is as a media tor between labor and management, being fair to each and applying the bask; sdentific and ethical principles of medicine for the' benefit of all. By putting in at least part tune in industry, the physician will be helping to supply a gratifying demand for much-needed medical advice in indus try; aiding immeasurably in maintaining the na tion's defense and security; helping extend to more people the privilege of being productive; contributing to research if he wishes; and assisting organized medicine to assert its proper position of leadership in a crucial period in this nation. umncu 1- MiBer, toward: Annual toporf an Occepattoaal Health tor*Mi U- ft. Public Health tomes is Council ea Icdusmal Health American Medical Asseashea. Council minutes, 1*54. 2. Shepard. W. p. t oh "Essential* of Public Health," I. B. Upptneott Cotapcrny, Philadelphia. 2d ed^ 1952, Chapter I. S. Mttrepohtm Ut laeura&ce Compand*"Employee Health iemce Is ImaP Plcmts.^Ipd^tnal Health ftim He. I, 4. Inamuim Aaonrlh The Extent ef Voluntary Health _ Insurance Caverafe,tn the United State*,*' Noreaber, 19M. 5. "A. M. A Congress ee Industrial Health," Industrial Modi* One end Surgery. VeL 24. No. S. March. 1955, p, 194. I. rnmnlssina ee Medical Care Plans (appointment by Board of Trusts>). Journal of American Medical Ansocsanen, Vet 147. fefacuarr 12. IMS. p, SH. 7. "Striding Principles of Occupational Medicine." Jcarnal of Aaencoa Medical A racoonnu. VeL 1U, Mar 22, 1954. pp. . r +w . * :-A, ' T * ' V : k -ifc 1 l-- \ v-' v;;. . ... /' a.. The Importance of the Private Practitioner to Industrial Medicine ' A > ; . V ` * ' i-' V * * . rv * \jr, ..*.7r * *. > <v%W V /V .. V *;->;> :;y~; *, L)`` **'.'1 ~ .ri '-V,'. . '*'<-I.,'. '- ... ;V. **. V `-.... ' ..;.* \ *',,V `I'-- . \ *"2 % "V i.' i :uVV-:"*- v- .1 vV * ' ?* ' 4iA'r.' i'y* V .'* T- ". '.; ";. '. A-V ' 7'rt .Av '' ' t. -^Vv.'w': -.-A -. -.. . . f * j. '' " 7,, JL WILLIAM P. SHEPARD, MIXv;>:: >r: Nkw Ycduc, Nw Yoblkr ' ' . V .! : . -S, . .:> ~ ... .. .. .. .. .. .. .. . - . i^ V-ii ''. . ' -I".. *: V .. V' f. '. .ir # .`A . : ' s ..7 s.. >; . . .V- , ;> ' .-. 1- . .V-.' ; - N ..: .^ , ' ' !*..7<<- '.7' .'- ' '<'.. jv-*v ' Kifriattd frca TW fim^wli ittjuml jpmtl, " imx va.;pt.. . O 1tl> tf lh IMal gnriky < h Imi < . .. Wnrt*i, H. ". ' ' _ -. .. f,;.'. ? '' ' ... ^'.v ` `'1:'. ' "**i ^Cr-S-ilv i'. ./\4r-'-Vv' ; .fi: ^ '^Kf^ " , 'T' . v- .' ' .7 V;-L v- ':Jl ' . . r ". '--Tt---TV- .'*-" * ' v':.f 'fy>,'', ** * ' *,Vr5*i 1 .v`a1. ; ' - .C-/. ' 7,. V^' .: . % **.,...i*- . , .. *..*' . _. * *V ' rv't* -<5> THE IMPORTAHCE DF THE PRIVATE PRACTITIONER TO INDUSTRIAL MEDICINE WILLIAM P. SHEPARD, MD. Ntw York, Hrw York MANY environmental changes occurring in recent years have had great impart on the now many areas where full- or part-time indus trial work is within driving distance of those still practice of medicine. The amiring advances in living on small farms. therapy and in diagnostic technique are well known to a medical audience. The sodologic and medico-economic changes are less well known, but oi almost equal importance. Along with this, we are only now beginning to feel the full impact oi the workmen's compen sation laws now in effect in every state of the Union. In effect they compensate the worker for Among the more important changes is the fact any disability incurred in and during the course that 121,000,000 of our population in this coun of his employment. Negligence by employer or try have been provided with, or have provided employee no longer determines liability. The themselves with, some kind of coverage against cost of compensating employees injured while at hospital expense; 109,000,000 have coverage for work, from whatever cause, is simply added to surgical expense, and 72,000,000 have some kind the cost of the product manufacture! of coverage for medical expense.1 Since 1940 the number having hospital coverage has increased tenfold, the number having surgical expense pro tection has increased twentyfold, and the num ber with regular medical expense protection has increased nearly 24 times. This has indeed in fluenced the practice of medicine. Among other things, it means the physician has many more forms to All out. It also means that a consider able proportion of his bills are paid, and paid promptly. Many physicians report as much as 50 per cent of their total incane derived from third-party payments. Some report as much as 85 per cent. Another remarkable phenomenon which changes the practice of methane is the rapid in dustrialization of this country, accelerating about the time of the first World War and proceeding with amazing rapidity in recent yean. Migration of our population from rural to urban areas has never been so great This means a marked change in the occupation of many of our people from rural to industrial pursuits. Not only have the people moved from farms to cities but indus try has moved to the country, so that there are And finally, among these socio-economic changes affecting die practice of medicine there is not yet felt the full impact of the court rulings of 1949 which, in effect, threw insurance benefits as well as wages into the arena of labor relations with all oi the implications that this involves. This had led, slowly at first but with increasing acceleration, to an enormous demand by man agement for medical services of certain specified types, and by labor for medical and hospital care for its members and their families. Let us consider now what these few but pro found economic changes have done to the respon sibilities, the privileges, and the skills demanded of the physician in the private practice of med icine. There is, indeed, hardly a private practi tioner in any specialty or in general practice who has not been affected. First of all, due to the universality of the work men's compensation acts, together with the gen eral tendency of those who administer these acts to be generous to the laborer, it often becomes of the utmost importance for the private practi tioner to distinguish with nicety and skill be tween a disability which occurred in and during Pmtatcd tt tb* eat taa4x4 cifktk tsso&l girita oi Tfcft Medical Seetcj oi tfct Suit oi Pcaatytra&i* is PUUddpkU. Oct. IS, ML Dr. Shepard h aedfcal dimtor of tW Mttropelhaa Uft Iwurxac* Cwpaay aad chtirmta of the fiwil ea Zadastvial Health of the .Astride Medseel Aemutiea. the course of employment and one which is un related to employment There is a natural tend ency on the part of many workers to blame any disability or even disaffection on their occupa- don. Too often the family physician or the spe cialist, perhaps unthinkingly, sympathizes with the patient in this view without making a really thorough investigation. Among the commonest incidents of this kind are the dermatoses. Skin disturbances of one kind or another account for more absenteeism in industry than any other single cause, except the so-called common cold. Occupation has been blamed and workmen's compensation awards granted for everything from adolescent acne to alopecia. There is no denying the fact that some industries do use some substances which are irri tating to the skin, especially to the skin of some people who are peculiarly susceptible to that par ticular substance. However, to be sure that a given skin disturbance is dne to occupation re quires careful and discriminatory diagnosis. It involves consultation with the medical director of the industry involved so that the exact nature of the substance may be ascertained and studied. It usually requires a series of pain staking patch tests, using the suspect substance against con trols. Not infrequently it involves consultation with a dermatologist who is familiar with occupa tional dermatoses and their prevention. The toxic substances encountered in industry having a systemic effect are legion in number and protean in their manifestations. Generally speak ing, when there is a medical director of the in dustry involved, he is well aware of die poten tially dangerous substances handled and of the preventive measures currently in use. In any suspected case be will be an invaluable consult ant. Generally speaking, the systemic effects of the relatively few toxic dusts are well understood in industrial medicine, as are the effects of the heavy metals and the fumes and vapors of the solvents. These may only occasionally come to the attention of the individual private practi tioner, thus accounting for some of the embar rassing mistakes we tee too frequently. A recent case in point is an inquiry in the Question and Answer section of the Journal oj the America* Medical Aetociaiion describing rather vague symptoms of vertigo, weakness, and loss of appe tite by a workman engaged in stamping letters on semi-solid objects in a retail store. Many people suffer such indefinite symptoms, but when this worker learned that two of his associates had what he thought were similar symptoms he was convinced that his difficulty was due to his occupation. Although it is not so stated in the Journal, subsequent careful investigation of this case indicated that the man was suffering from 2 chronic malnutrition and secondary anemia which he had had for many years and which had nothing to do with his occupation. Even the obstetrician may be involved in ques tions of industrial toxicology. We have seen an employer sued because a woman suffered a mis carriage which she thought was due to inhaling fumes from a small lead retort in a small business a block away. Nor is the pediatrician exempt from problems emanating from or related to industry. There is on record as "epidemic" of acute aniline poison ing among newborns in a hospital nursery. The hospital suddenly ran short of diapers, quickly, obtained a new supply, stamping them with the usual hospital insignia, the coloring for which contained an aniline dye. So acute was the short age that the new diapers were put into use with out washing, with the results described. Finally, for the physician who is oriented in psychosomatic medicine, the so-called stress dis orders are an ever-growing problem which may or may not be related to certain peculiarities in the patient's occupation. Recurrent hyperten sion, persisting or recurring peptic ulcer, manv of the arthritides, and some allergic phenomena may or may not be related to the individual's work. It requires all the physician's skill and judgment to decide. Is this illness related to deep resentment toward his "boss"? Is he actually overloaded with work (a rare phenomenon in the modern day) ? Is too much or too little skill expected of him? Or is he what my professor of psychiatry used to call just "an idiopathic con stitutional inferior"? Psychogenic as many of these disorders may be, they are distinctly med ical problems and will be solved only by medical skills. They deserve the best attention the pri vate practitioner can give them, including a con sultation with the industrial medical director, if there is one, or with the individual's immediate supervisor. Without further examples it must be clear that the practice of medicine and the demands put upon the private practitioner have been pro foundly changed by the phenomenally rapid in dustrialization of our country in the past 25 years. May I now point out another demand, and a relatively new one, which is placed upon the prac ticing medical profession by industrialization. To paraphrase Keboe,' we are surrounded to day by man-made hazards to life and health, the variety and extent of which we have never be fore seen in the history of the human race Mechanization and speed have so altered our working lives that one marvels at the adaptability of the mechanism. A jet pilot can collide with a visible object 10 miles away before the nerve impulse can travel from retina to muscles in time to avoid it A Univac machine will han dle 200,000 transactions on 800,000 accounts with the speed of light One operator on a hinge-bend ing machine can turn out 20,000 pieces a day; his grandfather at the forge did well with 20. All of these changes are blessings to mankind, but they place us and our patients in a new environ ment, presenting dangers to human structure and function such as we have never known. The industrial uses of chemistry, engineering, and physics have produced so many new prod ucts and by-products that many are in common use before their dangerous qualities are recog nized or understood. Chemists can produce and put into use a dozen new products while we painstakingly lay out a three-year research proj ect to test the toxic qualities of one. These changes are not confined to the factory or mine. Our homes and farms are mechanized and supplied with new products. They are usually to our benefit, but they bring us in close proximity with dangerous machinery, hazardous refrigerants, potentially dangerous drugs, insec ticides, and other chemicals. Add to this the fact that combustion products of one kind or another are discharged into our air at an unprecedented rate, reaching for the first time in history in some areas a saturation which is uncomfortable to muses of human be ings, and in a few places, and as yet on rare occasions, inimical to life and health. Our streams and lakes carry a pollution load such as we have never seen before, while at the same time, especially in the West, their flow has been lessened by Increased need for irrigation and water power. The products, by-products, and waste prod ucts of nuclear fission present a whole new array of man-made hazards. Their potential harm to man and all life on this earth even in peaceful uses almost paralyzes the imagination. Kehoe says; "It is not always apparent to us that this is a new, a strange, and as yet an inade quately explored human environment which we as medical men do not fully appreciate or under stand ; that we have a tremendous task of study, investigation, and adaptation ahead of us, and that all of the knowledge, skill, and resources of modern medicine and hygiene are being put to a more severe test of their applicability and fit ness than they have been in any previous period in the history of this country." We must respond to the increasing demands for industrial medical service from both manage ment and labor. More than three-fourths of the employers and two-thirds of the employees in this country are in businesses employing less than 500. These smaller organizations can rare ly, if ever, engage a full-time medical director. Whatever occupational health guidance is ob tained for their workers will usually come from a local physician willing to devote part time to in dustry. Industry's legal and humanitarian concern with the health of its personnel is to provide as safe and healthy a work place as possible; to safeguard and improve the physical and mental health of its employees by means of preventive medicine and health education; and to restore the worker disabled by occupational causes to productivity as quickly as possible.* What shall we do with the ever-increasing problem of medical service for the small indus try? One solution is that worked out by the Philadelphia Health Council many years ago, supplying small industries with a group of welltrained medical and ancillary services, the costs of which were prorated according to the size of the industry. This demonstration resulted in several other, communities developing similar facilities. It is to be hoped that this trend will continue. But for many years to come small in dustry will resort to the simplest expedient, that is, to obtain the part-time services of a practicing physician, preferably in the neighborhood, who will interest himself enough to do the kind of a job that needs doing. There are probably 20,000 physicians now de voting part-time service to industry. Many are quite satisfactory, others give it a minimum of their time and try to do the job from their office without going near the factory. Although many of the teachers of industrial medicine and the specialists in this field will disagree with this statement, it is my opinion that almost any welltrained physician who is willing can develop con siderable competence in this field. With indus trial medicine a slowly but surely burgeoning specialty, there are now available in almost all parts of the country competent specialists who may be called into the small industry to help out with special problems. In fact, industry is more accustomed to calling in specialist advisers than is the individual private patient With such help at his elbow, the part-time non-specialist in industry ctn deal with the great majority of medical problems which he will encounter. The physician is molded in the hierarchy of academic college, medical school, laboratory, and hospital. Over the centuries this ancient and honored hierarchy has given the public dedicated doctors, better prevention and treatment of HI* ness and injury, and longer, healthier life. But it is a rigid hierarchy, one which shapes char acter. For the physician it tends to become a way of life, often the only one he fully understands. When the physician enters the portals of in dustry, he encounters a different but equally rigid hierarchy. There is the same systematic layering of personnel according to rank and degree of responsibility to which be is accustomed in the teaching hospital; the same dearly defined chain of command; not a dissimilar system of super vised tutelage with apprentices instead cl interns and residents. But the physician's place in the industrial sys tem is quite different from that to which be ha* become accustomed. He is not top man as he is in the hospital or his private office. His services are strictly secondary to the mam purpose of the business--production at a profit His value de pends on his willingness and ability to work with others to achieve that main purpose. In industry he cannot give orders to all about him and expect them to be carried out promptly and meticulous ly. His word is not invariably taken as law. Administratively, he must prove the value of his recommendations, their reasons, probable results, and costa. The physician will be happy in indus try only if he can find satisfaction in being part of a non-medical team and can work in harmony with the members of this team, understanding why they do things in a certain way and explain ing why he must do things in a certain way. In short, industrial health work demands things from the physician which may not be required of him in other fields. Full justice can hardly be done industrial health work without spending regular hours at the plant, seeing employees seeking service and advice, inspecting work places periodically, and watching for potential hazards in new materials and procedures.* Perhaps the greatest responsibility of the phy sician is to protect the worker and management from unrecognized health hazards. Development of an occupational disability caused by a prevent able hazard but unknown to employer or em ployee discredits the alertness of someone. Let it not be the doctor! Prevention of even one such case may save enough in compensation costs to the company and lost wages to the victim to justify the expense of the medical program for many years. Industry has the right to expect the physician to have a high sense of medical ethics--to depend on him never to use his industrial connections to take advantage of his fellow physicians. He must respect and preserve existing good relationships between employees and their own doctors, and be able to work with other physicians in the com munity as a respected colleague and consultant The modern industry considers itself a good cit izen of the community. It supports local pro grams of all lands, including the health and wel fare agencies of which the practicing physicians are on important part In fact, with so many health benefits now included in the wage-earner's compensation, it is essential for industry to have good relationships with local physicians. Even a part-time plant physician can be an invaluable help in bringing about an understanding of these benefits by the local medical profession. The employee's own doctor working with the plant physician can do more than anyone else to pre vent abuses caused by an employee's misunder standing or faulty attitudes.' Above all, both management and labor have a right to expect the physician to be a neutral mediator in questions involving health. He must be fair to both aides, using his influence to help the injured workman obtain the benefits to which be is entitled, but also to protect the employer against unjustified daunt.* unuNcss 1. Taalftfc Ainai tnmy, Htafcfc laimatt flwinril. tt Ultima York 22. X- Y. 2. Kssat, L A.! Tk< Floe* at lodootriol UMkim ia MM- era Ifodtaal Practfct, Cmrinusai J. MM, 37: S3, foknaiy, 1354. 3. Seem, W. D,, X. C, tad Stoxmsl, W. L: Ptrtm--i Mmmfnmml, McCfiwHm, N** York, )& editva. J9I4, 9. 432-434. 4. Caatatii m l*4a*trtel Book* at the Am*riw Moitetl Ao* eiaticB. Tbt Stnvr of tk* Iodaitriai Ejrirwn. )43t 1317-1334, Doc. 1, 1354. 5. Prtac*to of K4kal Z&feo. ;^Jf^4,, 144:1434, Jo* 37, 1953. 4. Inss, F.: Doctor cad Werkmn'i Coapcnaotiao, 7*4m4 MM, & Swf^ 24:9, Joamry. 1937* 4