The Occupational Medicine Specialist in South Africa

THE OCCUPATIONAL MEDICINE SPECIALIST IN SOUTH AFRICA:

SCOPE OF PRACTICE

(May 2007)

Introduction

The infancy of the discipline of occupational medicine in South Africa and its with several other clinical and public health disciplines, requires the scope of practice to be clearly defined to allow specialists to conduct themselves in the most ethical manner possible and to ensure that clients’ expectations are met.

The mission of the occupational medicine specialist is to contribute to the maintenance of the quality of working life at the highest possible level. The Scope of Practice necessary to achieve this can be characterised in four major areas:

Leadership and Management
Healthy workers
Healthy working environment
Healthy work organization

The occupational medicine specialist will typically provide a high quality ethical service, both clinical and technical advisory, to organisations in the private and public sectors. The specialist will play a leading role in training, education and the development of the discipline of occupational medicine. If clinically based, the specialist will occupy a position at a referral level in the health service, and if managerially based, be involved in the development of policies and procedures to assist organisations to function more effectively in attaining healthy and safe working conditions.

Broadly, the occupational medicine specialist should possess a variety of skills, each based on a number of abilities or competencies. The specialist should demonstrate in practice an interdisciplinary or holistic perspective, and be able to(i) integrate perspectives and skills from a variety of disciplines in medicine, public health, management, law and social sciences, in problem solving at individual, group or organisational level; (ii) work effectively with a range of professionals and practitioners engaged in occupational health and (iii) reflect in problem solving an in depth understanding of the institutional, legal, and ethical context of occupational medical and occupational health problems.

A variety of different agencies have published “Scope of Practice” or equivalent documents for occupational medicine. These include the AmericanCollege of Occupational and Environmental Medicine (ACOEM), the Faculty of Occupational Medicine (FOM) in the UK, as well as the Scope of Skills outlined in the South African College of Public Health Medicine (Division of Occupational Medicine) (CPHM (DOM)). The World Health Organisation (WHO Europe) has published its own Scope and Competencies for Occupational Medicine, and the CPHM (DOM) has opted to base its own “Scope of Practice” on this extensive document. This document must be read in conjunction with the CPHM (DOM) Regulations, June 2004.

1. Role of the occupational medicine specialist

The prime responsibility for the health and safety of workers rests with employers. The occupational medicine specialist’s role is to advise them on how to:

identify and assess the risks from health hazards in the workplace;
protect and promote workers’ health;
carry out surveillance of factors in the working environment and working practices which may affect workers’ health;
improve working conditions and the working environment;
maintain the health of the enterprise as a whole by providing occupational health services to workers and (through expert advice) achieve the highest possible standards of health and safety in the interests of a particular working community;
strengthen workplace health promotion -a continuous process for enhancing the quality of working life, health and wellbeing of all working people through improving the physical, social and organizational work environment;
develop work organization and a working culture which supports health and safety at work and promotes a positive social climate and smooth operations, thus enhancing the productivity of the undertaking;
use human resources management to increase the working capacity and ability of employees to cope better with the demands of working life.

2. Core competencies for specialist occupational medicine specialists

The fully specialised occupational medicine specialist is competent to carry out the following functions.

identification and assessment of the risks from health hazards in the workplace:
undertaking workplace assessments and advising on control methods;
diagnosing work-related ill health;
organizing appropriate investigations for diagnosis of occupational disease;
recognizing the need for specialist assessment of the working environment through use of othermultidisciplinary team members (toxicologists, hygienists, ergonomists, organizational psychologists, etc.) and organizing the team;
surveillance of workers’ health based on legal requirements, the magnitude of occupational risks to workers’ health or by voluntary agreement:
pre-placement health screening and medicalexaminations;
periodic examinations;
exit examinations on leaving the enterprise;
other medical examinations;
biological exposure monitoring;
biological effect monitoring;
surveillance of the factors in the working environment andworking practices which may affect workers’ health:
monitoring of workplace hazards including physical,chemical, biological, ergonomic, psychosocial andother hazards;
organizing and undertaking workplace inspections;
organizing health surveillance for workers exposed tooccupational hazards;
selecting biological monitoring on the basis of criteriaof validity for the protection of the health of the workerconcerned, with due regard for the sensitivity,specificity and predictive value of the tests concerned;
advising on occupational health, safety and hygiene,ergonomics and on individual and collective protectiveequipment:
assessing control systems designed to eliminate orreduce exposure;
selecting appropriate personal protective equipmentwith the assistance of other experts as required;
advise on the ergonomic design of the workplace and working tools;
organising first aid and emergency treatment:
advising on the provision of first aid facilities andemergency procedures;
advising on the planning and organization of work including the design of workplaces, the choice, maintenance and condition of machinery and other equipment, and on substances used in work:
advising on the introduction of new working systemsand techniques;
including the human factor in the process design of theenterprise, workplace and working tools;
participating in and guiding the process of formulating health and safetypolicy based on sound ethical principles:
advising management and workers’ representatives onthe ethical basis for a policy;
advising on the need for full consultations withworkers’ representatives;
advising how to choose and define health and safety targets whichshould be achieved by the enterprise in a specified time;
coordinating discussions leading to agreement by bothmanagement and the workforce representatives;
ensuring workers are fully informed of the policy andof their rights;
advising on tools to be used for monitoring andevaluating enterprise policy outcome;
Promoting the adaptation of work to the worker; assessingdisability and fitness for work. Promoting work ability:
risk assessment of workplace hazards (as above) withadvice on prevention of harm;
assessment of disability and fitness for work,pre-placement and following work-related illness/ injury;
assessment of impairment, disability and handicap inrelation to work;
clinical management in rehabilitation of disabledworkers;
application of ergonomics to rehabilitation;
application of organizational psychology to rehabilitationin situations of work-related mental ill health;
counseling employees regarding sickness absence;
management of workers with drug or alcohol problems;
advising on rehabilitation and redeployment;
advising on maintaining aging and disabled workers inwork;
promoting work ability: health, skills and training inrelation to the demands of work;
advising on fitness for work and adaptation of work to theworker in the special circumstances of vulnerable groupsand specific legislation;
collaborating in providing information, training andeducation in the field of occupational health, safety andergonomics to management and the workforce:
communicating with people from various backgroundsand with different levels of technical understanding;
organizing and writing reports as precisely andquantitatively as possible;
making clear oral presentations;
organizing data bases (including computerised databases and (possibly) websites) for the disseminationand publication of research in occupational health andsafety matters;
counseling;
participating in committees, in particular the health andsafety committee;
participating in analysis of occupational accidents anddiseases;
communicating with other professionals to organizeand deliver training appropriately;
contributing to scientific knowledge regarding hazards tohealth and safety at work, by research and investigation intohealth and work ability problems at work, following theethical principles attached to research work and to medicalresearch and including an evaluation by an independentcommittee on ethics, as appropriate:
conducting a formal scientific investigation;
carrying out a literature search and preparing a report;
interpreting scientific data in journals and from ownresearch;
planning simple surveys;
recognizing and initiating the investigation of workability, health determinants and disease in the workforce;
analysing routinely collected data, including sicknessabsence and accident data;
reporting regularly to management and workforceorally and in writing.;
advising on, supporting and monitoring the implementationof occupational health and safety legislation:
application of occupational health law and ethics toindividual cases;
advising managers on the implementation of health andsafety and environmental law;
advising on health and safety policy;
advising workers and workers’ representatives of theirlegal obligations;
evaluation of compliance with new legislation;
recognising and advising on hazardous exposure in thegeneral environment arising from industrial activities:
differential diagnoses of work-related and environmentalrelateddisease;
identifying, assessing and advising on the prevention ofenvironmental hazards arising, or which may result,from operations or processes in the enterprise;
recognizing and advising on hazardous exposures in thegeneral environment arising from other sources oractivities;
liaising with other specialists responsible forenvironmental and community health;
participation in workplace health promotion programmes:
health promotion needs analysis of the workingpopulation;
analysis of the ethical aspects of health screening;
cost-benefit analysis of work-related health promotionactivities;
advocating and managing an agreed workplace healthpromotion programme;
seeking participation of workers and employers in thedesign and implementation of work-related healthpromotion and working ability maintenance programmes;
evaluating and auditing workplace health promotionprogrammes, especially with regard to their relevanceto occupational health hazards in the workplace and thecontrol of non-occupational determinants of health andworking ability;
management of the occupational health service (OHS):
assessing the occupational health needs of the enterprise;
defining the goals and objectives of the OHS;
defining the roles of staff in providing an OHS andformulating job descriptions;
management of the occupational health department orservice using quality management principles;
evaluating the quality of service provision includingaudit of the professional medical aspects of occupationalhealth care;
negotiating and managing a budget;
team-building;
record-keeping;
designing a training programme for occupational healthstaff;
working as part of a multidisciplinary service:
leading the team;
hiring experts;
advising on implementation of other professionals’ riskassessments;
coordinating health surveillance and biologicalmonitoring with environmental surveillance and otherrisk assessments;
promoting multidisciplinary scientific work onexposure data gathering;
planning the efficient use of multidisciplinary resources;
contributing to the selection of criteria to be used toevaluate own service practice.

3. Areas of Knowledge and skills

3.1 General clinical knowledge and skills

Through experience, the occupational medicine specialist has theknowledge and ability to carry out the following functions:

accidents, emergency medicine and surgery:
provide acute medical care for common injuries andillnesses;
stabilize casualties and refer them to specialist centresfor emergency care;
diagnose and manage physical hazards and injuriesassociated with heat, cold, radiation, lasers, sound andvibration;
cardiovascular disease:
recognize, assess and manage cardiac effects ofasphyxiants and other cardiotoxic substances;
assess workers with cardiovascular disease and theirfitness for work and rehabilitation or redeployment;
assess abnormal electrocardiograms and refer tospecialist services as appropriate;
assess workers for peripheral vascular andcerebrovascular disease and manage them appropriately;
dermatology:
undertake clinical differential diagnosis of skin diseasesand occupational causes by history, examination anddiagnostic evaluation;
manage occupational and environmental skin injuriesand dermatoses;
identify and advise on control of occupational andenvironmental risk factors for skin disease;
ear, nose and throat:
identify, diagnose and manage in the occupationalsetting patients with common occupational andenvironmental ear, nose and throat conditions includingallergies, granulomatous disease and chronicinflammatory disorders;
diagnose noise-induced hearing loss;
carry out and interpret an audiogram and implementappropriate treatment and preventive measures in theworkplace for the assessment and control of noise;
haematology/oncology:
assess, diagnose and prevent the known adverse effectsof workplace exposures on the haematological system;
assess, diagnose and prevent known adverse effects onhealth of substances known or suspected to becarcinogens;
investigate causation in cases of suspectedoccupationally caused cancer;
infectious diseases and travel medicine:
identify, manage and prevent infectious diseases ofemployees and of travellers;
manage appropriate immunization programmes forworkforces and travellers;
prevent and manage ill health effects arising from poorhygiene and sanitation and exposure to food, water, air,blood or waste contaminated by pathogens;
prevent and manage infestations and zoonoses;
mental health:
take a complete psychiatric and psychosocial historyand carry out a mental state examination;
diagnose psychiatric disease and refer patients (whereappropriate) for specialist treatment;
identify work-related psychological and psychosocialstressors and advise on appropriate organizationalremedial and preventive measures as well as treat andrehabilitate the worker;
identify and manage the impact of psychologicalconditions on fitness for work;
assess the impact of psychotropic medication on fitnessfor the specific job;
manage workers suffering from mental ill health in thecontext of legislation on disability;
design, implement and evaluate ethical workplacepolicies on alcohol and substance abuse;
advise, design, implement and evaluate alcohol andsubstance abuse testing programmes in the workplace;
provide appropriate support and counselling forworkers affected by such policies and programmes;
musculoskeletal conditions:
recognize diseases and disorders of the musculoskeletalsystem;
identify, diagnose and manage acute and chronicmusculoskeletal disorders and associated disabilities;
advise on ergonomics and their applications inmusculoskeletal conditions;
assess fitness for work in the presence of adversemusculoskeletal conditions;
design and manage rehabilitation programmes in thecontext of musculoskeletal conditions;
identify and manage chronic musculoskeletal painsyndromes;
neurology:
perform neurological and mental state examinationsand assess occupational and environmentalneurological disease or injury and fitness for work;
advise and request diagnostic procedures for assessingneurological conditions caused by occupational orenvironmental factors and refer (where necessary) forspecialist assessment;
advise on rehabilitation of patients with neurologicalconditions;
ophthalmology:
identify, assess and manage occupational eye injuriesand disease and refer (where appropriate);
develop and manage vision screening and protectionprogrammes and establish fitness for duties;
assess workplace risks to vision and plan andimplement eye protection programmes;
reproductive medicine:
occupational and environmental exposures toreproduction and effects on male and female fertility,
pregnancy, the foetus and the breastfed infant;
advise on control of risks to reproductive capacity inthe workplace;
advise on management of the pregnant worker in thecontext both of the Code of Good Practice on the Protection of Employees during Pregnancy and after the Birth of a Child(under the basic Conditions of Employment Act) and inthe specific context of known hazards to pregnancyoutcome;
access sources of up-to-date reproductive toxicologyinformation;
respiratory medicine:
advise on work-related and environmental respiratoryhazards, their risk assessment and control;
advise on statutory requirements to protect workers andthe community from the effects of workplace hazards tothe respiratory system;
diagnose, manage and refer (where necessary) forspecialist assessment and treatment cases of respiratorydisease;
oversee the conduct of diagnostic tests including spirometry,chest radiographs and immunological tests (where appropriate) andinterpret the results of respiratory diagnosticinvestigations;
design, manage and evaluate respiratory protection andscreening programmes in the context of occupationaland environmental respiratory disease;
toxicology:
advise on occupational and environmental toxicology,absorption, metabolism and excretion of principal toxicsubstances encountered in the workplace and theenvironment and their effects on health;
advise on policies to eliminate or control toxicsubstances hazardous to health;
plan and implement emergency measures to deal withchemical hazards;
assess clinical and worksite data along with literaturereviews to evaluate risks to workers’ or communityhealth.

3.2 Knowledge areas and skills in occupational medicine

The occupational medicine specialist should have sufficient knowledge and clinical skills to enable him/her to:

provide high quality medical diagnoses and advice on treatment of occupational and environmental injuries and disease;
advise on patient care with an understanding of workplace hazards and exposures;
provide best practice advice on care aimed at the patient’s functional recovery, which is the clinical aim;
take a comprehensive history emphasising occupation and exposure;
carry out complete or focused physical examinations, as required;
select appropriate diagnostic studies;
identify the relationship between the complaint and the exposures;
identify non-occupational/environmental factors contributing to the occupational disease or injury;
refer or follow up patients with occupational injuries or disease;
elicit patients’ concerns about exposures and establish a therapeutic relationship incorporating risk communication;
report all findings to affected individuals.