a. Health Assurance Medical Departments

physician has the specific knowledge, experience, or facilities to perform the tests, surveillance,

or control as do the other members of the health and safety department, nor do the latter typically

have the medical knowledge to operate independently. However, both groups should be able

to obtain the help required from the other.

The size and complexity of the facility ultimately determines the size and complexity of the

medical branch of the health and safety department. It is the responsibility of the employer t o

know when, where, and how to obtain medical personnel to provide medical services for the

employees. The AMA (American Management Association) and the American Occupational

Medical Association have plans and pamphlets containing much information to help devise and

implement a medical facility.

In a small facility, the number of employees and the nature of the work dictate the extent of

health monitoring. Clerical employees should be able to avail themselves of the medical facility,

but may not need general physical or specific testing, unless, as is becoming more frequent, air

quality problems arise stemming from the construction of energy efficient buildings in recent

years. On the other hand, workers exposed to asbestos, toxic chemicals, or radiation would require

more complete and frequent examinations, testing, and monitoring. In a small facility without

undue usage of toxic chemicals or hazards, a trained nurse, paramedic, or physician's assistant

might be qualified to do all that is necessary and refer more complicated problems to a contract

physician or hospital.

According to Dr. Marcus Bond, 5,7 a work force of 300 that includes employees who require

periodic monitoring and medical examinations can justify an in-plant medical department with

a full-time nurse and a part-time physician. For 100 to 300 employees, a part-time nurse, paramedic,

or physician assistant might suffice; for 300 to 800 employees, one full-time nurse is usually

sufficient. A part-time physician could be on call or spend a specified number of hours at the

plant. A group of employees numbering 800 to 1500, including a substantial number who require

physical and environmental monitoring, will justify a full-time physician and at least two industrial

nurses.

This is an opportunity for a family practice physician6 to participate in a part-time capacity

in industry. It must be of some interest for the physician or else motivation would be missing in

the proper medical and psychological care of employees. It is an opportunity to further involve

themselves with patients and the functioning community. Statistics indicate that primary care

physicians provide about 80% of employee medical care. Only 20% of plant physicians are

occupational physicians. In the U.S., financially secure companies continue to have a full-time

physician for approximately each 3000 employees, although some industries are known to have

only one for about 15,000 employees. Indeed, there are a few substantial companies which have

no full-time physician regardless of the number of employees. This might be because of low

exposure or toxicity in the facility or because a commercial medical clinic is contracted to care for

their employees (HMO, PPO, emergency clinics).7

The acceptance of a health program by both management and by those actually manufacturing the product, whether it is paperwork, nuts, bolts, chemicals, or research, is by a slow

accrual of satisfied patients. There is an inherent suspicion and skepticism by both areas.

Management needs to know that they are complying with federal and state mandates and would

like to see a positive productivity gain as a result of health expenditures. The workers find it hard

to believe that management would venture a program other than for financial gain. It is gratifying

to observe the progression of acceptance by both vital areas in programs that succeed. 8 It has

been amply shown that it is cost effective to have a good health program with caring personnel.

The employees are healthier, happier, and more productive; the turnover of workers decreases,

lessening training expenditures; loss time for illness or injuries decreases both because of attitude

and from instruction and training in “wellness;” workers who feel as though they are an integral,



©2000 CRC Press LLC



functional, and productive part of a facility are more content to stay on the job until retirement.

Environmental stress is diminished and managed14-17

The physician who accepts the challenge of participation in a health program should obviously be able to perform the usual functions of a general physician, and, in addition, should

be knowledgeable in the psychology of workers, the hazards and conditions in varying work

sites, toxicology, and communicable diseases in the workplace.11,12 Recognition of such problems

as drug abuse, alcoholism, and the effects of smoking is mandatory. Although this is a very broad

background, we must consider that patients/workers are male/female, and young/middleaged/elderly.

The occupational health examination8,9 may be divided into three areas:

1. Pre-employment or pre-placement

a. medical history

b. occupational history

c. physical exam

d. laboratory and X-ray (if needed)

e. multiphasic screening

2. Periodic examination (with interval history)

a. annual physical examination or at desirable intervals

b. executive physicals 10

c. toxic or hazardous exposure bioassays

3. Special examinations

a. food handlers

b. job transfers (if markedly different)

c. return to work after serious illness or injury

d. retirement examinations (document final condition and advise as to future health and

wellness)

e. fitness classification

These areas of assessment (1) determine the immediate health state, any change since

previous examinations, and the suitability to work in any area; (2) will suggest advice and

modalities to enhance or improve health; and (3) may indicate conditions of stress or unhealthy

situations in the environment needing attention and change.12

The results of an examination should be kept confidential. A layperson should not be

expected to interpret the results and make decisions as to employment on that data. The physician

does not hire or advise that a person should be hired. That is a corporate decision. However, the

physician can categorize the pre-employee or employee into several levels:

1. Fit for general work - physically and mentally.

2. Fit for work only in specific categories -physically or mentally.

3. Unfit for employment at this time - presence of a medical condition requiring attention.

When corrected may be eligible for employment.

4. Incapacitating condition - illness, injury (old or new), or mental illness of a chronic nature.

These would prevent employment in either a general category or a specific category.8

The validity of the physician's assessment would depend on his knowledge of the required

work conditions of the specific facility and his ability in disability assessment.11 It is also an

introduction to the applicant or employee of a caring medical resource within the company or

university. The perception of the physician as a “company doc” is really an uncomplimentary

epithet. Fostering the perception of a caring physician really interested in the pat ient, who also

happens to work for the establishment, will contribute to a more accurate assessment as well as



©2000 CRC Press LLC



help maintain healthiness at work.

Many applicants and employees are educationally deficient, but this must not be interpreted

as low intellectual capacity. Very often, the appreciative patient will indicate that they had always

wondered about a condition, but no doctor had ever taken the time to discuss it in

understandable terms. The results of a small amount of expended time are very gratifying.

The initial assessment of an employee should be comprehensive. The elements of a specific

company's products should dictate the specific areas to be assessed beyond the general.

Obviously, an individual who is to do heavy lifting of any kind should have musculoskeletal and

neurological systems carefully examined. Whether X-rays are mandated is still a moot point; they

really are of marginal value generally. If there is a suggestion of a problem which would make Xrays of value, either on the physical or from the medical history, X-rays must be taken. On the

other hand, exposure to chemicals, gases, heat, cold, radiation, etc., would need more specific

scrutiny in other systems. The initial medical history is completed by the applicant prior to seeing

the physician, and carefully reviewed in the applicant ' s presence. Some areas can be amplified

and clarified during this time. Encouraging questions by the patient at this time emphasizes

caring. Following this, a careful physical examination is carried out.8 It is probably a good idea

to discuss findings on the physical examination as it proceeds. When the examination is

completed, proceed to other testing. If specific findings during the physical mitigate again s t

performing certain tests, the routine can be modified. Some tests may be done by the physician,

nurse, or a technician. They might include color perception, visual acuity audiometry, spirometry,

glaucoma, and electrocardiography. Note that some tests, such as the one for glaucoma, are not

normally occupationally related, but initial screening is relatively easy to do and detecting these

things will enable the employee to seek additional medical help. There are some tests, such as

a blood panel or urinalysis, which require laboratory services. All of these are mainly screening

tests. Positive findings may, and probably should, be referred back to the patient *s physician

or to an appropriate specialist. The industrial physician must not be in competition with outside

physicians. By the same token, if the patient signs an authorization, a complete copy of the

examination can be forwarded to them or to the physician of their choice. Under ordinary

conditions, it is not wise or proper to refer an employee to a specific physician unless that

physician is the only one able to perform a given function. A list of qualified names can be

provided for referral. This also contributes to harmonious relations with the local medical

community.

Subsequent physical examinations of employees should be spaced appropriately to the nature

of their jobs. The questionnaire may be abbreviated if they indicate the absence of changes. The

physical, however, should be as careful and complete as at the beginning. This will naturally

reveal any changing status, i.e., needs glasses or hearing aids, dermatitis, tumors, glaucoma,

asbestosis, etc. Finding any deviation from normal early is a real bonus to treatment. By the time

some symptoms are obvious to the patient, it may be too late. As an old medical professor once

said, “There's a lot of pathology out there. All you have to do is find and recognize it.” It is the

responsibility of the physician to adhere to three dictums or duties:

1. Prevent disease.

2. Diagnose and treat to the best of your ability.

3. Help the patient’s demise to be with as much dignity as possible. Good rapport will allow

this.

The industrial physician may want to compose or purchase pamphlets appropriate to the

specific facility and leaflets or booklets on general health-promoting ideas: smoking cessation,

cholesterol control, back care, weight control, why and how to exercise, etc. How much good

these actually do is not well documented, but employees do pick them up and carry them home.

Perhaps even small dollops of advice absorbed will contribute to the enhancement of



©2000 CRC Press LLC



healthfulness. Recently the author's institution added a wellness program available to all of the

employees (including retired) and spouses instead of just the occupationally challenged. An

excellent response was obtained, which may indicate that there is a substantial level of interest

in employer-sponsored health programs, and positive results may improve the overall health of

the participants.

The highly motivated industrial physician should have the facilities to address most environmental, factory, and facility problems. If management recognizes and adequately funds a

health assurance program, tangible evidence of the health improvement (reflected in decreased

loss time) would be found to be cost effective. Intangible evidence is hard to accrue, but well

employees are likely to feel more content with their work and remain with the company longer,

and are more likely to accept healthful ways of work and pursue similar attitudes at home.

Health assurance is an important element of a well thought out and implemented health and

safety program. It is cost effective, humane, and generally good administrative policy to provide

such a program.



REFERENCES

1.



LaDou, J., Ed., Introduction to Occupational Health and Safety, National Safety Council, Chicago,



2.



1986.

Council of Occupational Health, AMA: Scope, objectives and functions of occupational health programs,



3.



Council on Occupational Health, AMA: A management guide for occupationa1 health problems, Arch.



4.



Environ. Health, 9, 408, 1964.

Guide to Developing Small Plant Occupational Programs, American Management Association, Chicago,



5.



1983.

Bond, M.B., Occupational health services for small businesses and other small employee groups, in



JAMA, 174, 533, 1960.



Occupational Medic me: Principles and Practical Applications, Chicago, 89, 1988.

6. Howe,H.F., Small industry: an opportunity for the family physician, Gen. Pract., 26, 166, 1962.

7.

8.



Knight, A.L. and Zenz, C., Organization and staffing, in Occupational Medicine, Principles and Practical

Applications, Chicago, 1988.

Collins, T.R., The occupational examination: a preventive medicine tool, Continuing Med. Ed., 77,

February 1982.



9.



Guiding Principles of Medical Examinations in Industry, American Management Association, Chicago,

1973.

10. Thompson, C.E., The value of executive health examinations, Occup. Health and Safety, 49, 44, 198 0 .

11. Disability Evaluation Under Social Security, A Handbook for Physicians, Social Security Administration,

Baltimore, August 1973.

12. Occupational Diseases. A Guide to Their Recognition, U.S. Dept. of Health. Public Health Ser., Pub. no.

1097, U.S. Government Printing Office, Washington, D.C., 1966.

13. Felton, J.S., Organization and operation of an occupational health program, .1. Occup. Med, 6, 25,

14. French,J.R., Caplan, R.D., and Von Harrison, R., The Mechanism of Job Stress and Strain, Wiley

of Studies in Occupational Stress, John Wiley and Sons, New York, 1982.

15. House, J.S., Wells, J.A., Landerman, L.R., et al., Occupational stress and health among

workers, Health Soc. Behavior, 20, 139, 1979.

16. Kahn, R.L., Conflict, ambiguity, and overload: three elements in job stress, Occup. Ment. Health,



1964.

Series

factory

3, 2,



1973.

17. Selye, H., The Stress of Life, McGraw-Hill, New York, 1956.

18. Description and Evaluation of Medical Surveillance Programs in General Industry and Construction, Final



©2000 CRC Press LLC



Report, Office of Regulatory Analysis, Directorate of Policy, Occupational Safety and Health

Administration, U.S. Department of Labor, Washington, D.C., 1993.

19. Stokinger, H.E., Means of cont act and entry of toxic agents, in CRC Handbook of Laboratory Safety,

2nd ed., Steere, N.V., Ed., CRC Press, Cleveland, OH, 1971, 314.



2. A Health Assurance Program

A formal Health Assurance (HA) program should not be intended to replace an environmental

monitoring program but to complement one. In an earlier section, some of the limitations of a

monitoring program for chemical exposures were mentioned, but the main point, which should

be appreciated, is that we do not necessarily know what are “safe” exposure levels. Indeed, safe

levels may not exist, only levels in which the negative effects attributable to an exposure

disappear into the statistical noise caused by the presence of other parameters. This is especially

true for individuals, with their wide range of susceptibilities. In many instances, even this level

of knowledge is not available since the data are not available, simply because the studies have

not been performed. For example, the ACGIH tables incorporate several hundred chemicals and

the OSHA PEL levels for a few less, but this is very small compared to the 50,000 to more

than100,000 (according to various estimates) commercial chemicals already in use, to which must

be added hundreds of new ones developed yearly. Further, the number of studies establishing

safe levels for synergistic interactions of combinations of materials is virtually nil, as often as

not associating the effects of a material with an easily measurable personal habit, such as whether

the exposed individual smokes. The prospect of conducting synergistic studies, with all the

combinations involved, is obviously not bright.

Regulatory requirements for a number of materials now specifically mandate employee access

to an employer-supported medical surveillance program designed to monitor problems associated

with the specific chemical. Many authorities recommend participation in programs for anyone

who works with toxic substances during the normal performance of their duties. However, there

are few specific recommendation on what actually constitutes a significant involvement with toxic

materials which should trigger participation in an HA program. This will be discussed further later

in this section. The content of the examination will depend to a great extent on the duties

associated with the job. However, as noted in the previous section, there are some components

of a HA program which are universally agreed upon as essential:

1.

2.

3.

4.

5.



A medical history

A prior work history

A pre-placement examination

Periodic reexaminations

An end of employment examination



The entire program should, in addition to a number of standard components, be tailored to

the anticipated types of exposures. As these exp osures change during alterations in the research

program, the periodic reexaminations can be modified to reflect the changing conditions.

Even before the HA program is initiated, there are a number of key ethical issues which must

be addressed. If participation in a HA program is to be required as a condition of employment,

the advertisement for position should so state. Further, the examination must be clearly intended

to determine if the duties would be such as to make it unsafe or very difficult for the employee

to perform the work or would aggravate an existing health problem. If reasonable adjustments

can be made in the duties or responsibilities, then the examination cannot be used to discriminate

against an otherwise qualified applicant. This issue is basically the premise of the Americans

With Disabilities Act. (Note that a U.S. Supreme Court Decision just made, in June 1999, says

that if the condition causing disability is readily correctable, such as by wearing glasses, the

employer can not be held liable for discrimination).The employee should have an assurance of



©2000 CRC Press LLC



confidentiality. There are factors which may be health related, but which have no bearing on the

ability of an employee to do the work assigned, and which cannot harm those with whom the

employee would come into contact. The employee has the right to expect that any such

information remain confidential. Finally, the employee should have access to the results of the

examination and any tests performed and should be able to authorize release of the data to others,

such as the persons family physician, if they so desire.

a. Participation

If the organizational approach is to provide an examination based on need, then the necessity

arises to define criteria as to who should be included and who should not. Individuals who do

not work with chemical or biologic agents or where their duties are not unduly stressful or

physically hazardous can be justifiably excluded for these reasons. On the other hand, in the first

few years of operation of an HA program at the author’s institution, approximately 20% of the

participants were found to have medical problems of which they were not aware and which should

be treated. In such cases, they were encouraged to seek medical assistance from their family

physician. If this is typical of the typical employee population, it could well be to the employer’s

benefit to screen all prospective employees to secure a healthier and more productive workforce.

However, since the intent of a HA program in the current context, as applied to research

personnel, is to monitor the impact of chemicals or pathological organisms on the health of the

individual (either directly or indirectly, e.g., wearing a respirator can place a burden on a person

with impaired pulmonary function), exposure to chemicals and biologically active (to humans)

agents should be a major factor to be considered in the participation of an individual in a HA

program. OSHA requires access to a medical program for persons working with regulated

carcinogens or who are exposed to human blood, tissues, and other fluids, and those required

to wear respiratory protection, among others (a list of the OSHA sections requiring medical

surveillance programs is provided as an appendix to this section). However for other substances

the toxicity of the material, the mechanism of exposure, the duration of the exposure, the intensity

of the exposure, the safeguards available to prevent exposure, the current state of an individual's

health, and prior exposures all play a part in the decision.

If an individual is working with an agent which is significantly infectious to humans, there

appears to be little question that participation in a medical program is needed. Although the

probability of contracting a disease increases with higher exp osure rates, once contracted, the

characteristics of the disease are not dependent upon continued exposure or the initial level of

exposure.

If a major portion of an individual's time is spent working with a regulated carcinogen, other

regulated materials such as lead or cotton dust, or other materials which meet the criteria for being

highly toxic, corrosive, a sensitizer, or an irritant, then again it is usually required or desirable for

the individual to be in a medical program. Even if facilities are available, such as totally enclosed

glove boxes in which the work is done, it is arguable that unplanned exposures could occur, and

the conservative approach would be to include rather than exclude the person. It could be argued

also that if the exposure levels are maintained sufficiently low, then participation in a program

is not needed. It is on this basis that OSHA defines exempt levels for meeting some of the

regulatory requirements for some of the regulated carcinogens. However, documentation of the

low levels would appear to be required to deny access of an individual to a medical surveillance

program on this basis. Of course, participation in a HA program is clearly indicated if a monitoring

program provides information indicating that the individual uses materials of concern or is in an

area where others use them and is actually exposed to airborne concentrations which are typically

a significant percentage of acceptable levels.



©2000 CRC Press LLC



Where the use of respiratory protection is indicated, then the OSHA standard for respiratory

protection in 29 CFR 1910.134(c) includes the statements: (1) In any workplace where respirators

are necessary to protect the health of the employee, the employer shall establish and implement

a written respiratory protection program with work site specific procedures. ... The employer shall

include in the program the following provisions...(ii) Medical evaluations of employees required

to use respirators; and in 29CFR 1910.134(e) is the following:

“Medical evaluation. Using a respirator may place a physiological burden on employees that

varies with the type of respirator worn, the job and workplace conditions in which the respirator

is used, and the medical status of the employee. Accordingly, this paragraph specifies the

minimum requirements for medical evaluation that employers must implement to determine the

employee's ability to use a respirator.”

(1)



(2)



(3)



(4)



(5)



(6)



General. The employer shall provide a medical evaluation to determine the employee's

ability to use a respirator, before the employee is fit tested or required to use the

respirator in the workplace. The employer may discontinue an employee's medical

evaluations when the employee is no longer required to use a respirator.

Medical evaluation procedures.

(a) The employer shall identify a physician or other licensed health care professional

(PLHCP) to perform medical evaluations using a medical questionnaire or an initial

medical examination that obtains the same information as the medical questionnaire.

(b) The medical evaluation shall obtain the information requested by the questionnaire

in Sections 1 and 2, Part A of Appendix C of this section.

Follow-up medical examination.

(a) The employer shall ensure that a follow-up medical examination is provided for an

employee who gives a positive response to any question among questions J.

through 8 in Section 2, Part A of Appendix C or whose initial medical examination

demonstrates the need for a follow-up medical examination.

(b) The follow-up medical examination shall include any medical tests, consultations,

or diagnostic procedures that the PLHCP deems necessary to make a final

determination.

Administration of the medical questionnaire and examinations.

(a) The medical questionnaire and examinations shall be administered confidentially

during the employee's normal working hours or at a time and place convenient to

the employee. The medical questionnaire shall be administered in a manner that

ensures that the employee understands its content.

(b) The employer shall provide the employee with an opportunity to discuss the

questionnaire and examination results with the PLHCP.

Supplemental information for the PLHCP.

(a) The following information must be provided to the PLHCP before the PLHCP makes

a recommendation concerning an employee's ability to use a respirator:

(b) The type and weight of the respirator to be used by the employee;.

(c)The duration and frequency of respirator use (including use for rescue and escape);

(d)The expected physical work effort;

(e) Additional protective clothing and equipment to be worn; and

(f)Temperature and humidity extremes that may be encountered.

(g)Any supplemental information provided previously to the PLHCP regarding an

employee need not be provided for a subsequent medical evaluation if the information and the PLHCP remain the same.

The employer shall provide the PLHCP with a copy of the written respiratory protection

program and a copy of this section.



©2000 CRC Press LLC



Note to Paragraph (e) (5) (iii): When the employer replaces a PLHCP, the employer must

ensure that the new PLHCP obtains this information, either by providing the documents directly

to the PLHCP or having the documents transferred from the former PLHCP to the new PLHCP.

However, OSHA does not expect employers to have employees medically reevaluated solely

because a new PLHCP has been selected.

(7)



Medical determination. In determining the employee's ability to use a respirator, the

employer shall:

(a) Obtain a written recommendation regarding the employee's ability to use the

respirator from the PLHCP. The recommendation shall provide only the following

information:

(b) Any limitations on respirator use related to the medical condition of the employee,

or relating to the workplace conditions in which the respirator will be used,

including whether or not the employee is medically able to use the respirator;

(c) The need, if any, for follow-up medical evaluations; and

(d) A statement that the PLHCP has provided the employee with a copy of the PLHCP's

written recommendation.

(e) If the respirator is a negative pressure respirator and the PLHCP finds a medical

condition that may place the employee's health at increased risk if the respirator

is used, the employer shall provide a PAPR (powered air supplied respirator) if the

PLHCP's medical evaluation finds that the employee can use such a respirator; if

a subsequent medical evaluation finds that the employee is medically able to use

a negative pressure respirator, then the employer is no longer required to provide

a PAPR.

(8) Additional medical evaluations. At a minimum, the employer shall provide additional

medical evaluations that comply with the requirements of this section if:

(a) An employee reports medical signs or symptoms that are related to ability to use

a respirator;

(b) A PLHCP, supervisor, or the respirator program administrator informs the employer

that an employee needs to be reevaluated;

(c) Information from the respiratory protection program, including observations made

during fit testing and program evaluation, indicates a need for employee

reevaluation; or

(d) A change occurs in workplace conditions (e.g., physical work effort, protective

clothing, temperature) that may result in a substantial increase in the physiological

burden placed on an employee.



Persons who do not have a continued exposure to chemicals, but periodically perform tasks

requiring intense uses of chemicals for a brief period, such as in agricultural field experimentation,

should probably be included in a HA program. Not only are many agricultural chemicals quite

toxic, but the working conditions place severe physiological stress on the research personnel

and their support staff. Respirators should be worn, as should clothing which will not be

permeable to the chemical sprays. Respirators place stress on the pulmonary and cardiac system;

protective clothing which is impermeable to fumes and vapors usually does not transpire either,

and the body temperature will rapidly increase since the clothing prevents heat from being carried

away from the body by evaporation, conduction, or convection of perspiration.

Persons who have known health problems that could be aggravated by the exposures

involved in their job duties or who have had prior work histories where they could have had

significant exposures to chemicals that could have sensitized them to chemicals in the workplace



©2000 CRC Press LLC



or that could have initiated delayed effects also would fall in a category which should be

considered for participation in a HA program.

It is most difficult to determine whether persons for whom the exposures are marginal, i.e.,

where the portion of their duties in which they use chemicals is limited, but they do use materials

part of the time with properties that could cause ill effects should be included in a HA program.

It would be easy to establish a criterion that any use whatsoever should qualify a person for

participation. However, many activities of normal everyday life involve use of such items as

gasoline and household products containing toluene, acetone, phenol, isopropyl alcohol, ethyl

alcohol, hydrogen peroxide, acid, and caustic materials such as lye, which certainly are toxic

materials. The “any use” criterion is undoubtedly too liberal, unless one simply admits that there

are no selection criteria and includes every employee. A compromise which appears reasonable,

but which has no other scientific justification, is to arbitrarily select a percentage (such as 10%

of a typical work week) for actual use or exposure to a chemical or combination of chemicals of

average health risk as a threshold. An employee approximating an exposure of this level could

be asked to fill out a form listing the chemicals which are in use in their vicinity and an estimate

of the average time each are used. This form should be reviewed by a physician (preferably with

a background in environmental and occupational medicine, if one is available) and his recommendation should govern the question of participation or not. However, if an individual wishes

to be included, but who might not be recommended, probably should be permitted to do so.

Although every person who has duties which could give rise to health problems should be

a participant, it is especially critical to include permanent employees. Many of the tests which

are run on the individual have a sufficiently wide “normal” range (except in extreme cases of acute

exposure, where the individual should definitely receive medical attention anyway) that a single

examination may not be particularly informative. However, problems due to environmental work

conditions, as will be discussed later, may be revealed by trends shown by comparison of

successive examinations.

b. Medical and Work Histories

The medical history and prior work histories are key components of any health assurance

program. There are any number of health-related factors for which a heredity predisposition exists,

so that the medical history will normally include a segment concerning family members,

particularly parents. Obviously, known prior medical conditions will be of importance.

Emphysema, for example, would certainly be of concern if the employee were to have to wear a

respirator frequently during the course of his duties. Hypertension and heart problems would

clearly be of importance if the job involved significant physical stress, and of course there are

chemicals which directly or indirectly affect the heart function. Medical history forms vary

substantially in content but one used for a HA program should be comprehensive. It is part of

a record which, along with the prior work history and the actual examination, including tests

which may be run, will constitute the baseline against which changes in the employee's health

will be compared to determine if occupational exposures are having a negative effect on the

employee's health. Some prospective employees are inclined to conceal previous illnesses if it

is likely to affect their chances of obtaining a desired position. This is unfortunate but quite

understandable. It is important, if these conditions later manifest themselves, that they have been

detected, if possible, by appropriate questions or during the pre-placement examination. The need

to do so stems from a desire (1) to avoid responsibility for an occupational exposure causing the

diseases and (2) to explain any problems which do develop on the possible basis of occupational

exposures experienced by the individual.

The prior work history serves essentially the same purpose as does the medical history. For

example, a prospective employee who would be working in agricultural research programs might

have had a previous period of employment working with pesticides and herbicides, which could



©2000 CRC Press LLC



have had a depressant effect on his cholinesterase enzyme levels. It would be important to

include a test of this parameter in the pre-placement examination. Even some nonchemical

activities, such as previous work in a heavily dust-laden atmosphere, might have caused a

decrease of pulmonary function to an extent that an individual might find it impossible to wear

a respirator to provide protection against solvent fumes. Previous exposures to some chemicals

or substances may result in effects delayed for many years, such as the latency periods generally

associated with carcinogens. Among other substances for which any history of prior exposures

might be elicited would be asbestos, dusts, welding fumes, heavy metals, pesticides; herbicides;

acids, alkalis, solvents, dyes, inks, paints, paint thinners, paint strippers, gases, radiation, etc.

If there are any specific areas of concern because the work regimen will involve materials known

to have a possible impact on a given physiological function, or organ, then the physician should

supplement the standard questionnaire for both the medical and work histories with questions

designed to elicit as much relevant information as practicable.

There are any number of common diseases which are not necessarily related to an occupational exposure but which could be a risk in the work environment. Diabetes and

hypertension are certainly not necessarily work related, but the individual, unless treated, could

be a hazard to one’s self and potentially to co-workers. Similarly, a disease of the eyes, such as

glaucoma, could interfere with a person's ability to see properly, but many persons could be

unaware of its onset as it is an insidious disease, primarily a problem to persons over 40. A

relatively simple automatic instrument is available to detect pressure increases in the eyes, which

is a sign of the disease, and which would permit the physician to refer persons to an

ophthalmologist. Loss of hearing could be a problem if persons do not hear warnings and, again,

many persons do not realize that this has become a problem or are reluctant to admit it, even to

themselves, as a sign of increasing age. Although these problems should have been brought

to the attention of the individuals by their family physician, a surprising number of persons do

not have a family physician or do not see one frequently. As noted earlier, at the author's

institution, approximately 15- to 20% of the persons participating in the HA program for the first

time had reasonably serious problems of which they were unaware, and which could have placed

them at risk, or at best, reduced their efficiency and productivity. The scope of the examination

should be sufficient to detect these conditions which may not be job related.

c. Pre-Placement Examination

It would be highly desirable if a pre-placement exam could be given prior to any work exposure

to provide a true baseline for the individual. However, unless a medical examination has been

an integral part of an organization's employment procedure since the inception of the company

or institution, then instituting a HA program will always catch a number of current employees

already in the midst of research programs involving exposure to hazardous materials. A medical

examination at this time will still have significance in the sense that future examinations can still

be compared to the earlier one to detect changes during the interval between examinations.

However, the information gained in the exam, including any test results, will not necessarily

reflect the normal conditions for the employee. If, for example, an individual has been working

within the organization using agricultural chemicals and has a very low level of cholinesterase

enzyme at the time of the initial examination, it may be suspected that the employee's work has

caused the depressed level of the enzyme to occur, but it is uncertain. The individual may be one

who has a naturally low level. If a person is tested at the time of initial employment, then the effect

of the working environment on the parameters measured in the examination will be much more

apparent, although the effect of work exposures on an individual may be confused if similar

exposures are likely to occur outside the workplace. In the example just used, if the initial

examination revealed a normal enzyme level and a later one showed a depressed value, perhaps

after a suspected exposure, then the initial conclusion, barring any alternate exposure mechanism,

would be that an exposure had occurred and remedial steps taken to prevent further exposures

and to prevent future incidents of the same kind. Where alternate exposure conditions exist

outside the workplace which could have caused the same conditions, then there could be

problems for the employee receiving financial compensation for the problems, such as workmans

compensation.

The other major purpose of a pre-placement examination would be to avoid placing a person



©2000 CRC Press LLC