An unashamed promotion of the specialty of Occupational Medicine – based on my own experience and biased perspective of the specialty !

Professor David Ferguson – Australia’s ‘Father’ of Occupational Medicine

Anyone who has spent time in Hobart and watched TV will have heard the used car commercial that says “WHY DO I DO IT'” when the business owner offers an enticing trade-in offer. I am certainly not suggesting that occupational physicians are in any way like used car salesmen, but I do get the impression that other doctors wonder about the attraction of working in this field of medicine.

A new doctor has joined my practice. This has led me to reflect about the specialty of Occupational Medicine as a career choice for a doctor embarking on a medical career. I hope he reads this!

I recently discharged a patient with great satisfaction. The patient had been referred late in the course of the claim, at the suggestion of the insurer. A somewhat unusual situation as most referrals come from other doctors and perhaps earlier in the course of a claim. The patient was severely depressed with very high pain levels from an orthopaedic injury and had contemplated suicide. The previous specialist involved in the care hadn’t been listening and only proposed medication or further surgery as the solution. The care had become disjointed. The patient was very frustrated to say the least. My practice was able to provide coordinated care including pain management and allied health care, as well as provide information to both the patient’s own lawyer and the insurer about residual impairment and future medical needs (in addition to a lot of information to the patient). The claim was settled without too much angst. I think even the insurer was satisfied with the outcome. While the patient wasn’t able to go back to work, on discharge was coping much better, pain levels had settled markedly and advice was given about future work options. Cynics would say this was because the claim settled, but the improvement was evident well before settlement. The patient thought there was now a future and hinted that a life had been saved. Perhaps it had!  I do think we helped the patient negotiate the system and get out in the best shape possible. Any speciality other than occupational medicine would have had difficulty in that role.

Perhaps occupational medicine does have something unique to offer!

How has the specialty of Occupational Medicine been viewed?

Recent social media posts from the Faculty of Occupational Medicine (FOM) in the United Kingdom have encouraged doctors to become occupational physicians by extolling the attractions of the specialty. As a part of a recruitment drive in February of this year, FOM tweeted – ‘Choose a speciality with wide clinical variety where no 2 days are ever the same’ and ‘Interested in a medical speciality that trains you to be a leader?’ Perhaps the recruitment drive reflects continuing problems with the status of Occupational Medicine in the UK.

Social Media and contact with a German-trained colleague have illustrated the German approach to occupational medicine. Each business has a legal requirement to appoint an occupational physician, but the reality is that there are too few occupational physicians and many businesses in Germany are apparently in contravention of this law. I am told though that in Germany Occupational Medicine is relatively low in the ‘pecking order’ of medical specialties.

There has also been some negativity about occupational physicians expressed on the websites of Injured Workers support groups, suggesting that their opinions don’t carry the same weight as the opinion of other specialists.

Within the field of medicine, Occupational Medicine has been seen as a ‘poor cousin’ to the high-profile specialities, like Neurosurgery. This is rarely openly stated, but it is clear that there has been a lack of respect from other specialists towards occupational physicians, at least in the past. This is probably because it is a relatively new speciality, the areas of expertise are misunderstood or that the training programme has been seen as insufficiently rigorous. Most medical specialities entail an in-depth understanding of the diseases of a particular body system and their treatment, whereas Occupational Medicine covers the relationship between work and health across the entire spectrum of health disorders, both physical and psychological. Some occupational physicians have gained the reputation of supporting insurers and employers to deny treatment, providing further fuel to the concerns of other doctors whose focus is on their patient’s needs.

The status and recognition of Occupational Medicine as a medical specialty has been mentioned in recent informal discussions I have had in a variety of settings – medico-political, medical, insurance and legal. The value of specialist qualifications in occupational medicine and the role of a specialist occupational physician in the workers compensation field is, I think, becoming increasingly recognised.

Acceptance by the Courts?

In recent weeks, I have been asked to give evidence in three different courts – the Commonwealth Administrative Appeals Tribunal, the Tasmanian Supreme Court and the local Workers Rehabilitation and Compensation Tribunal.  One of the matters settled before my evidence was required, however the relatively unusual experience of being asked to appear in court as an expert witness on three occasions in such a short space of time emphasised the growing recognition of the role of an occupational physician as an expert witness. Other occupational physicians also figured prominently in those giving evidence. I have observed over the years that if opinions don’t carry weight in court the practitioner very quickly stops being asked to appear in court.

Does this reflect increasing recognition by the legal fraternity that occupational physician’s opinions have value in higher level legal processes? I think so.

My Own Career Experience

I will digress to provide some background about my own career in occupational medicine.

I undertook my undergraduate medical training at the University of Adelaide completing my training in 1979. I hadn’t grown up in Adelaide nor did I belong to a family of doctors. Initially I wanted to gain entry into the surgical training programme. I am not sure why now, but it seemed like the right thing to do at the time. Certainly to be a surgeon had Kudos, the potential to help people and good income. I became frustrated as it seemed that those who gained entry were those who were already part of the Adelaide medical establishment and I didn’t have a ‘look in’, or perhaps I just wasn’t good enough.

In 1981 a job with the Hydro-Electric Commission (known as the Hydro) as the general practitioner in the construction town of Tullah on Tasmania’s rugged West Coast was brought to my attention. As I was born in Hobart there was an attraction to working in the state of my birth for a year or two, while I decided on a career direction. I took the job (there were probably no other applicants) and was given enormous responsibility as a newly graduated doctor with responsibility for a Medical Centre servicing a remote community of over 2000 people, a nursing staff of 5 and the state’s second biggest ambulance service (more than 6 ambulances, I recall).

This environment was a great introduction to the ‘coal-face’ of workplace health and safety. The Hydro workforce undertook hazardous dam construction activities, including underground tunnelling operations and workshop maintenance, not to mention the road hazards with wet, windy and slippery roads and what was known as the “Tullah 500” as workers escaped each weekend from the West Coast to return to their families on the NW Coast or other parts of the state. During this period there were a number of industrial and road fatalities which brought home to me the ultimate consequence of workplace hazards.

The Tullah Medical Centre had responsibility for workforce health programmes, such as the relatively new concept of hearing conservation. I duly took my part in conducting audiometric programmes for the workforce along with the nurses, often starting early and travelling to the work site to conduct tests before work began. Alcohol and drug issues were also evident.

Professor Niki Ellis

Dr Niki Ellis (now a professor with international standing as an Occupational Medicine Academic) was a young occupational physician employed by the Tasmanian Health Department along with Dr Martin Bicevskis (later my training preceptor). She visited Tullah and impressed me with her enthusiasm for occupational medicine. Her visit was my first real awareness of the specialty, having never had any exposure as an undergraduate or newly trained doctor. She later developed a video about the newly identified risks of RSI, a radical approach for the time!

Dr Martin Bicevskis

I applied to do the 3 month course in Occupational Medicine at the University of Sydney in 1984 and was very lucky to have the support of my employer to attend the course. I had the fortune to meet Professor David Ferguson, Australia’s father of Occupational Medicine and other notable figures in the field. I think the Hydro were prepared to do almost anything to keep a doctor for their West Coast construction operations. Before me they had employed a doctor who had become notorious as one of the first doctors convicted of Medicare fraud!

I had the interesting experience of being the Hydro’s doctor at a very interesting time in Tasmanian politics when there was controversy about the building of the Gordon below Franklin Dam, when Bob Hawke intervened to prevent its construction. At the time ‘Greenies’ as they were known travelled to the West Coast to protest and one night camped at the Tullah Oval – a very provocative move, but I don’t remember any serious injuries from clashes with the Hydro workforce.

I completed the Sydney Course, and again with the support of the Hydro, I was offered the opportunity to set up one of the state’s first occupational health units, based at Head Office in Hobart. The position was recognised as a training position towards specialist qualifications in Occupational Medicine, with Martin Bicevskis as my preceptor. All I had to do was to recruit a doctor to replace me on the West Coast. Not an easy feat, but I achieved that with Dr Alfonso Messieh from Sydney who took over my role in Tullah. I understand is still working in Tasmania to this day, although he didn’t stay long at Tullah.

In Tasmania at the time Occupational Physicians only existed within organisations. I worked with the Hydro, Dr Tim Stewart worked at the ZincWorks, Dr Andreas Ernst worked at Comalco. In the Public Sector there was Dr Helen McArdle and Dr Martin Bicevskis. How that has changed! There are now no privately employed Occupational Physicians in Tasmania.

In Hydro Head Office, I started to realise the power of Occupational Medicine. We brought in one of the state’s first Smoke Free Workplace Policies to a workforce of over 5,000. I realised that such a policy had the power to assist hundreds of employees quit smoking. This is much more powerful than working 1 on 1 with patients! We had initiatives to deal with ‘RSI’, developed strategies for rehabilitation for both work-related and non-work related conditions, health promotion programmes as well as dealing with specific occupational hazards, e.g. the carcinogen creosote that was still being used to preserve very old ‘wood stave’ pipelines.

I also had experience in dealing with health and industrial relations aspects of asbestos, most notably at the Bell Bay Power Station in the state’s north. A wealth of ‘hands on’ experience. I am indebted to Peter Sutczak, staff counsellor and Heather Scott, occupational health nurse who worked with me at that time and opened my eyes to gender equality and the psychological consequences of injury and many other aspects of workplace health and safety. It was during this period that I met Phil Dening, a doyen in the field of vocational rehabilitation who went on the take an important role in Injury Management with various insurers.

I was involved in controversy too, not always over occupational issues, but in my role as manager of the Hydro’s medical services. A senior nurse employed as the Hydro township of Tarraleah in the central highlands of Tasmania used her sick leave to attend a school camp. Hydro Human Resources made an example of her and she was duly sacked for abuse of her entitlements. The Tarrleah community responded. A strike by the power unions followed  and I was embroiled in an industrial dispute than nearly ‘switched off the lights’ in the state. It was interesting to observe first hand the interaction between the Premier and the Hydro General manager in response to this situation, at a time when some people thought the Hydro was more powerful than the government. The upshot however from an occupational medicine perspective was my interest in what came to be called ‘absence management’. I realised the workplace culture in some areas was of acceptance of use of the annual entitlement of sick leave for other purposes. As a result of initiatives I helped develop, the Hydro put in place policies and procedures to address absenteeism and change the cultural attitude towards use of sick leave.  The leave entitlement system was changed to what became known as ‘No-debit sick leave’ where employees did not receive an annual entitlement to sick-leave. Other organisations, like Forestry Tasmania later followed with similar changes.

After I presented a paper at the national occupational physicians conference in Hobart, the College of Occupational Medicine (as it was then known) developed a guideline on Managing Absenteeism (a joint effort between SA occupational physician Peter Jezukaitis and myself). While this work has now been superseded by publications such as Realising the Health Benefits of Work this involvement demonstrated the potential for occupational medicine to have a broader impact on health issues in the workforce, in addition to  productivity and industrial relations issues.

I had another brush with notoriety that lead to my loss of confidence in the main stream media. I have detailed that experience in an earlier blog article. Why Insult & Injury?

I have had continuing contact with another occupational physician, Dr Helen McArdle during most of my professional career. Helen was working with the State Electricity Commission in Victoria when I first had contact, but has worked with the Tasmanian Health Department now for many years. We worked together in the early years setting up an occupational health service for the Royal Hobart Hospital, that replaced the earlier general practice clinic for hospital staff.

I left the Hydro in the early 1990’s to join a newly formed private vocational rehabilitation business. It was here I started to understand the dynamics of private workers compensation insurance, having been shielded from the ‘cut and thrust’ of private insurers with the Hydro as a ‘self-insurer’ for much of the time I worked there.

I had involvement with FAI Insurance’s Doug Smith and Colin Fagen and developed a respectful relationship with that organisation, providing rehabilitation services, that were recognised at the time as making a significant impact by reducing their claims costs. Colin went on to take a very senior role with QBE insurance. Later on FAI helped bring down HIH insurance after their two businesses merged, but I take no responsibility for that! I also met Peter Easther (now retired) who worked with TGIO, GIO and Vero Insurance. His approach seemed to exemplify an even-handed approach providing claimants with the opportunity to recover from their injuries.

During this period I developed an understanding of the rehabilitation industry and had the pleasure of interacting with some of the leading Tasmanian practitioners in the field. Maureen Rudge was a true pioneer, I recall hearing about her initial forays into the field of vocational rehabilitation while I was still working on the West Coast. Maree Webber is another practitioner who stands out along with Phil Dening and more recent people in the industry like Peter Wheatley.

During this period I also undertook OH&S audits across a variety of Tasmanian industries, which assisted my understanding of the dynamics within small and medium-sized businesses including Tasmanian icons like Blundstones, Hazell Bros and Gunns Timber. I was particularly impressed by the culture of the Underground Mining Equipment Manufacturer, Dale B Elphinestone, based in Burnie, later bought out by the multinational Caterpillar. Again, organisational culture could be seen as having an enormous influence of workplace health and safety performance. In the case of Elphinstone’s you could see the culture started right at the top with Dale Elphinstone himself, but the enthusiasm of WHS practitioners like Terry Clarke who made it all work.

During the period when I worked with the Hydro and while operating a rehabilitation and OH&S business, I was relatively isolated from mainstream medicine. Coming back into more contact with other doctors when I changed career tack to become a Consultant Occupational Physician in my own private Hobart Practice in the late 1990’s made me more aware of the culture within the field of medicine, that is difficult to identify from within. This topic might be the subject of a future article.

I had the opportunity to host Dr David Fitzgerald as a trainee occupational physician at my practice. David has gone on to set up an Occupational Medicine unit with Emirates airlines, based in the Middle East, but continues in a training role for ‘Remote area’ occupational physician trainees in Australia.

Dr David Fitzgerald

Most recently I have become involved in a medico-political processes. I was involved in the committee that helped develop the WorkCover Tasmania guidelines for the assessment of impairment. Another controversial area! I had the pleasure of working with occupational physician, Dr Dwight Dowda, Australia’s leading figure in impairment assessment during that process.

Dr Dwight Dowda in Fiji

I was involved as the medical board member with Asbestos Free Tasmania Foundation and worked with Simon Cocker former Secretary of Unions Tasmania in that role to enhance awareness about community risks from asbestos. Most recently I have worked with the AMA where there has been the opportunity to interact with general practitioners and other specialists. Involvement with the AMA WC Reform Committee and the AMA – Insurer Forum has illustrated to me that the training and experience of occupational physicians has a lot to offer. Most doctors do not have the benefit of an overview of how compensation processes work. This work has brought me into contact with interstate occupational physicians, like Dr Kevin Sleigh in Victoria who has a role with the Victorian WorkCover Authority. This contact has provided a perspective on initiatives in Victoria such as their well established Medical Panel system and new approaches such as auditing of IME reports and jointly appointed IME’s.

It is only in recent years that I have had the opportunity for involvement in research and publication. Although I had input into the Absenteeism Guideline produced by AFOM in the early 1990’s, it was not until 2 years ago that I had an article published in a peer-reviewed journal – a case study of a new cause of interstitial lung disease identified at a Tasmanian Fish Farm. Last year I become involved with a University of Tasmania study about attitudes to our Workers Compensation System. Shivon Prakesh is the post-graduate student co-ordinating the research. I am at present trying to get another publication in a peer-reviewed journal, this time about the current status as what is colloquially known as ‘RSI’.

There have truly been ups and downs in my career spanning the last 30 years, but I remain content with my choice of career, especially looking back on what can be achieved in the field of medicine and more broadly by contributing to the protection of health in the workforce through work as an occupational physician.

Has Occupational Medicine come of age?

It is evident that there is growing respect for Occupational Medicine as a specialty from other medical specialists, in addition to the recognition already received from employers, insurers and lawyers.

I now routinely see recommendations from other specialists to obtain the opinion of an occupational physician on matters such as fitness to work for the patients under their care. There are increasing referrals from general practitioners asking for assistance with care for their patients within compensation systems. Hopefully this is not just because the general practitioner finds it too frustrating to deal with the system (although that no doubt is part of it), but because there is recognition of benefit from involvement of an occupational physician in terms of health outcomes.

Occupational physicians have medical knowledge across a range of medical and psychological domains, in addition to an understanding of the workplace and insurance systems that interact with our health systems to assist or retard recovery. No other specialty has that scope.

In Tasmania at least there is still a way to go for acceptance at a Government level. There is currently no real acceptance by WorkCover Tasmania of any special role for Occupational Physicians in our compensation systems, although there has been some discussion about that possibility with the proposed Medical Advisory & Mentoring Service. It is ironic that the Australasian Faculty of Occupational and Environmental Medicine (AFOEM) publication Realising the Health Benefits of Work is promoted by WorkCover, but not the speciality of Occupational Medicine itself.

Some might see the development of Occupational Medicine as a another example of specialists taking over more and more of the traditional territory of general practice. It seems clear to me that the management of complex work-related health issues should be the domain of specialist occupational physicians providing guidance to other medical practitioners, as well as the other parties in our compensation systems.

Occupational Medicine is also the specialty best equipped to provide advice at a government and strategic level about the medical aspects of workers compensation systems.

While the current occupational medicine training programme might be more academically rigorous than in the past, I don’t think it can substitute for the cut and thrust of the variety of experience that I had the privilege of having over my career. It is crucial that Occupational Medicine trainees continue to have a breadth of experience  in different settings, and with a variety mentors to get the experience that can’t be gained from work in a single clinic or workplace or from research and classroom learning.

Occupational Medicine is a great specialty!

It gets you out and about into the real world of business, making a contribution to the economy and community.

You can make a difference to people’s lives, at an individual level, an organisational level and, in the right circumstances, at a societal level.

For those doctors contemplating a career in Occupational Medicine, the speciality allows work-lifestyle balance. It is a family friendly specialty where there is usually no on-call or shift work.

True, there is a lot of paperwork and reports, and at times involvement in conflict, but the intellectual challenge of providing care for patients in a complex environment, explaining and interpreting health information to suit the audience (from illiterate worker through to business executive and the judiciary) and the satisfaction of success as a doctor helping a worker recover, outweighs any negative aspects.