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Occupational and environmental medicine

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Occupational and environmental medicine (OEM) is a multifaceted medical field encompassing two main disciplines: occupational medicine, concerned with preventive health and work-related injury; and environmental medicine, concerned with the effects of the environment on health.1 Work and environment are important determinants of health, and general practitioners (GPs), as whole-person care providers, recognise the importance of considering a patient’s current and past occupation, the work environments these jobs exist in, as well as the broader environments in which we live and their impacts on health.

Over 500,000 people are estimated to experience a work-related injury or disease each year, with men experiencing workplace injuries more frequently when compared to women.2 Work-related injuries can include musculoskeletal injury, dermatological diseases, outbreaks of communicable diseases, ophthalmological injuries and psychological injury, while in rural areas, farming accidents can have significant impacts.3 GPs play an important role in treating these conditions and assisting patients in their return to work. They can also be involved in assessing a patient's fitness for a new job or change of category.1,4,5 GPs need to have a clear understanding of harmful exposures related to a range of occupations and be able to work with patients and organisations, where required, to prevent work-related illness and promote wellness.1,5

Work is an important social determinant of health and participating in ‘good work’ is health protective, contributes to improved self-esteem and a sense of identity. GPs are well placed to guide and educate their patients on the health benefits of good work.6 Furthermore, as workplaces and employment types continue to evolve (eg the rise of working from home and the increase of labour hire firms),1,7 GPs need to stay informed of changes to occupational medicine presentations and their related medico-legal responsibilities. General practice itself is a workplace and practice owners, managers and employees need to ensure it is a safe place for those employed there.  

In providing comprehensive healthcare, GPs need to consider the effects of the physical environment. Environmental medicine encompasses environmental hazards generated by industry (eg air pollution or chemical spills),1 the health effects of environmental events (eg natural disasters), as well as specific risks posed to patients living and travelling throughout Australia. More broadly, it describes the fundamental dependence of human health on a healthy environment. Spending time in nature has been associated with a range of physical and mental health benefits, including lower rates of chronic disease.8

Human health is dependent on the world’s natural environmental systems to provide clean air, fresh water, food and a stable climate. The World Health Organisation recognises that ‘Climate change is the greatest threat to global health of the 21st century’.9 Climate change directly affects health through increased frequency and severity of extreme weather events (including extreme heat, bushfires and associated air pollution, floods, storms and droughts). Climate change indirectly affects health through a myriad of systems including infectious disease (diarrhoeal and vector-borne), airborne allergens (triggering asthma, dermatitis and allergic rhinitis) and food and water insecurity. These changes can contribute to population displacement and conflict.10-12 They also cause a significant burden of mental ill health. Importantly, climate change is exacerbating pre-existing health inequities.13 For many Aboriginal and Torres Strait Islander individuals and communities, climate change is threatening to disrupt cultural connections to Country that are fundamental to health and wellbeing.14

GPs are well placed to identify and manage the adverse health effects of climate change and advocate for policy changes at the local, state, national and international level.15 Healthcare is responsible for 7% of Australia’s greenhouse gas emissions. GPs can address and reduce the health and environmental harms associated with healthcare by reducing low-value care and improving practice sustainability.

References
  1. The Royal Australasian College of Physicians. Occupational and environmental medicine training curriculum. RACP, 2013. Available at: [Accessed 2 December 2021].
  2. Australian Bureau of Statistics. Work-related injuries. Canberra: ABS, 2018 [Accessed 27 October 2021].
  3. Collie A, Pan Y, Britt H, Henderson J. Coverage of work-related injury and disease in general practice. Int JISSWC 2011;3(1) [Accessed 27 October 2021].
  4. Gray SE, Brijnath B, Mazza D, Collie, A. Australian general practitioners’ and compensable patients: Factors affecting claim management and return to work. J Occup Rehabil 2019;29(4):672–78. doi: 10.1007/s10926-019-09828-3.
  5. NSW Government State Insurance Regulatory Authority. Workers compensation guide for medical practitioners. Lisarow, NSW: SIRA, 2021 [Accessed 27 October 2021].
  6. The Collaborative Partnership to improve work participation. Principles on the role of the GP in supporting work participation. Canberra: Comcare, 2019
  7. Price-Gagnon, A. How labour hire will drive Australia’s economic recovery. ENTO, 2020 [Accessed 29 October 2021].
  8. White, MP, Alcock I, Grellier J. et al. Spending at least 120 minutes a week in nature is associated with good health and wellbeing. Sci Rep 2019;9,7730.
  9. World Health Organisation. WHO calls for urgent action to protect health from climate change – Sign the call. 2015
  10. Pendrey CGA, Beaton L, Kneebone JA. General practice in the era of planetary health: Responding to the climate health emergency. Aust J Gen Pract 2020;49(8):520–23.
  11. Nabeel I, Caraballo-Arias Y, Perkison WB, et al. Proposed mitigation and adaptation strategies related to climate change: Guidance for OEM professionals. J Occup Environ Med 2021;63(9):e650–e656.
  12. Lyons, A. A changing environment. RACGP Good Practice Issue 4, April 2017. East Melbourne, Vic: 2017 [Accessed 27 October 2021].
  13. Beggs PJ, Zhang Y, McGushin A, et al. The 2021 report of the MJA-Lancet Countdown on health and climate change: Australia increasingly out on a limb. Med J Aust 2021;215(9):390–92.e22 [Accessed 2 December 2021].
  14. Lowitja Institute. Climate change and Aboriginal and Torres Strait Islander health: Discussion paper. Carlton South, Vic: Lowitja Institute, 2021 [Accessed 2 December 2021].
  15. The Royal Australian College of General Practitioners. Climate change and human health: Position statement. East Melbourne, Vic: RACGP, 2019 [Accessed 27 October 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • respectfully ask about and discuss environmental and occupational factors involved in patient presentations
 1.1.1, AH1.3.1, 1.2.1, 1.2.3, 1.3.1, 1.4.4
  • communicate with workers about the diagnosis, management and prevention of common workplace injuries
 1.1.2, 1.1.6, 1.2.1, 1.2.2, 1.2.3, 1.3.1, 1.3.2, 1.4.1, 1.4.2, 1.4.3, 1.4.4, 1.4.5
  • effectively communicate with employers, insurers and relevant authorities regarding management plans, rehabilitation and the return of a worker to the workplace
 1.1.3, 1.1.4, 1.1.5
  • provide advice and advocate for patients to support them in realising the benefits of participating in good work and actively spending time in nature
 1.2.1, 1.2.2, 1.2.3, AH1.4.1, RH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • take a comprehensive history including eliciting information about a patient’s current and past occupation and environmental context
 2.1.1
  • undertake pre-employment screenings for patients
 2.1.1, 2.1.2, 2.1.7
  • assess a person’s capacity for work and identify factors likely to delay or prevent return to work after illness or injury
 2.1.1, 2.1.2, 2.1.3, 2.1.5, 2.1.6, 2.1.7, 2.1.8, 2.1.10
  • use a shared decision-making approach to develop management plans for work and environment-related aspects of common musculoskeletal, neurological, psychiatric, addiction, respiratory and dermatological disorders
 2.1.7, 2.1.9, AH2.1.2, 2.2.2, 2.3.1, 2.3.2, 2.3.4
  • coordinate with other health professionals and rehabilitation providers in managing an injured worker
 2.3.1, 2.3.2, 2.3.4, AH2.3.1, AH2.3.2, RH2.3.1
  • stay informed of developments in occupational and environmental medicine
 2.2.1, 2.2.2, 2.3.4
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • perform health surveillance and monitoring for patients in a range of occupations and environments based on their risk factors, for example, skin checks, respiratory monitoring, hearing checks or monitoring those vulnerable to the effects of extreme heat
 3.1.1
  • identify and discuss pre-existing and unrecognised, or insidious conditions that may be exacerbated by occupational or environmental factors
 3.1.1, 3.1.3, 3.2.3
  • identify environmental determinants of health and promote ways patients, communities and health professionals can improve their environment at a local, national and global level
 3.1.3, 3.1.4, 3.2.2, 3.2.3
  • implement strategies to improve environmental sustainability in the delivery of general practice care
 3.1.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • write an impartial medico-legal report or certificate regarding a worker, their injury, management, rehabilitation, prognosis and capacity for work
 4.1.1, 4.1.2
  • reflect on occupational and environmental factors in their personal and professional life and undertake actions to improve wellbeing for self and colleagues
 4.2.1, 4.2.2, 4.3.5, RH4.2.1, RH4.2.2, 4.3.1, 4.3.3, AH4.3.2
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • maintain comprehensive records regarding occupational history for all patients, and particularly in the case of workplace injury or incident
 5.2.2, 5.2.3
  • describe and fulfil the legal requirements when undertaking assessment and reporting fitness for work
 5.2.3, 5.2.4
  • identify and implement policies to manage environmental risks for patients in communities, including public health alerts in relation to infectious disease outbreaks, air pollution, thunderstorm asthma and extreme heat conditions
 5.1.1, 5.1.2, 5.2.5

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. It is important to take a thorough occupational history, including the patient’s job title and a description of the work, whether the patient can cope with the physical and psychological demands of the work, and if there are any previous workplace injuries or near misses. Having a focus on functional capacity rather than injury is a useful starting place for designing a return-to-work program in collaboration with an employer.
  2. Identify yellow flags and/or negative interactions between a person’s work and their medical conditions early to allow for advance planning rather than waiting until they are unable to work. For example, knee osteoarthritis in a tiler needs to be discussed in terms of occupational longevity.
  3. Understand which workers are covered under workers compensation schemes and which are not (eg some sole-traders or self-employed workers). Familiarise yourself with the relevant certificates of capacity in your state or territory.
  4. Familiarise yourself with the natural history of common workplace injuries, specifically low back pain and other musculoskeletal injuries. Know that you can refer to an occupational physician if you have a complex patient, feel out of your depth, or if a patient is not recovering within the expected timeframe. A good GP will be attuned to whether a patient is either not improving with initial interventions or deteriorating despite intervention. Similarly, if you have access to a rehabilitation provider, involve them as well as allied health providers early, as appropriate.
  5. Keep up to date with health information related to health conditions that arise from the changing environment, for instance, the disaster response to extreme weather events. Recognise that the health impacts from climate change are applicable to general practice (eg heat-related illness during heatwaves, the effects of smoke inhalation from bushfires, mental health impacts of climate-related events), and be able to identify and treat vulnerable patients.
  6. Keep up to date about long-term symptoms relating to environmental exposures and educate your patients on appropriate health surveillance for conditions unique to your geographic location; for example, Q fever vaccination in cattle farmers and respiratory surveillance in miners and stone masonry workers.
  7. Environmental influences on health are increasingly being recognised and applied in general practice.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Occupational and environmental medicine

Mercy is a 32-year-old factory worker who presents with a chronic eruption on both hands and daily rhinosinusitis. She has worked for three years for a food manufacturing company mixing ingredients, including soy protein concentrates with flour, sugar and salt.

The process results in aerosolisation/dust particles in the air. She is provided with a hairnet, but no other protective equipment. Within 30 minutes of this activity her eyes become pruritic and watery, and she gets itchy papules on the dorsum of the hands and neck. Her medical history includes seasonal asthma and allergic rhinitis in the spring that is usually managed with salbutamol. Last year, following a thunderstorm asthma public health warning, Mercy had an asthma attack and presented to the emergency department where she received treatment overnight, before being discharged home the next morning.

Questions for you to consider Clinical exam assessment area Domains

What aspects of the history are important to ask about?
  1. Communication and consultation skills
 1,2,5

What further information would you like to know about the relationship between Mercy’s symptoms and her work?

What would you look for when examining Mercy’s skin? Which areas of skin are of particular interest?

What other examination is important? Think of the respiratory tract and other mucocutaneous surfaces, such as the eyes and nose.
  1. Clinical information gathering and interpretation
 2   

What diagnoses are you considering?

Are there allergy tests that can be done in the general practice setting? What additional investigations would you order?

What additional diagnoses would you consider if Mercy worked as a hairdresser? Or a stone mason?
  1. Making a diagnosis, decision making and reasoning
 2

If Mercy’s initial RAST testing is positive for soybean, how would you manage her symptoms? What general measures could Mercy adopt in the workplace that may help alleviate her symptoms?

How might your management be different if her condition related to a psychological condition or bullying at work?
  1. Clinical management and therapeutic reasoning
 2   

How would you describe the possible diagnoses to Mercy and their implications for her current work activities?

What instructions would you give to the employer about restrictions and occupational health and safety precautions in the workplace?

Climate change has been associated with increased risk of thunderstorm asthma due to the release of aeroallergens with warmer temperatures and rising frequency of more severe thunderstorms. What is another example of how climate change is increasing environmental health risks?

How could Mercy's asthma management be changed to reduce the carbon emissions associated with the asthma management?
  1. Preventive and population health 
 1,2,3

Outline the relevant documentation that would be required if this were to be completed as a workers compensation claim.
  1. Professionalism
 4   

What treatment and rehabilitation measures do you need to consider when certifying a patient’s level of fitness for work? How do you assess response to treatment and ability to conduct occupational activities?
  1. General practice systems and regulatory requirement
 5   

Where would you refer Mercy for skin prick testing? Can you describe the procedure and interpretation of this test?
  1. Procedural skills
 2   

What timeframe would you consider for Mercy to return to work? What capacity will she have to conduct her duties when she returns?
  1. Managing uncertainty
 2   

How would you diagnose anaphylaxis? When would it be appropriate to ‘stand down’ a worker? Who can you refer a patient to in this scenario?
  1. Identifying and managing the significantly ill patient
 2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Think of a patient you have seen for a work-related issue. Identify any issues related to the social determinants of health unique to the worker.

  • What do you know about the relationship between work and health? Why is employment such an important determinant of health?
  • How could this patient’s work-related issues impact on their health?

Describe the impact of unemployment and underemployment.

  • Describe the physical, mental, social and financial benefits of employment and contrast it with the absence of these.
  • Have you had a patient who suffered the effects of unemployment and/or underemployment?

Where would you look for resources on environmental health in your local region? Examples might be RACGP Specific Interests Climate and Environmental Medicine, your Primary Health Network, or your state/territory health department.

  • How could these resources help you understand the impact of the environment on health? What did you learn from these resources?
  • How could you incorporate these resources and information into your practice, both when seeing patients and in terms of developing and using environmentally sustainable business practices?
With a supervisor

Consider local industries and large employers (eg agriculture, factories, education). Discuss with your supervisor the common work-related injuries and hazards for these industries, the risk reduction strategies and management principles.

  • What industries did you identify in your local area? Do you see any work-related injuries or hazards for these industries? How can you manage these issues?
  • Does your supervisor have any tips for you?

Identify complex presentations. An example is a pregnant skilled worker with a musculoskeletal injury. Ask your supervisor if they have had any clinical experiences where they were unable to find appropriate treatment guidelines for work-related presentations. Discuss how you would go about managing such a patient.

  • How do you work in these areas of uncertainty?
  • Who else do you involve in the patient’s care? What organisations or resources could you seek help from if needed?

Discuss what your approach would be to patients presenting with respiratory symptoms during a bushfire crisis.

  • How would you approach patients with a pre-existing respiratory illness? What about elderly and paediatric patients?

Discuss simple strategies to limit your environmental impact; for example, walking or riding to work or the shops rather than driving, and switching to renewable energy.

  • How did you go about identifying these strategies? Were there websites or other resources that had suggestions for you to consider?
  • Could you suggest any changes to your supervisor to reduce the environmental impact and energy use of the practice?
In a small group

Discuss the occupational risks of being a GP.

  • What biological hazards exist? What chemical hazards? What are the most common workplace injuries that affect GPs?
  • What occupational health and safety requirements are there to mitigate the risks for GPs at work?

Run a learning session for your group on the health impacts of extreme heat. Describe heat-related illness, including heat stress, heatstroke and the effects on current physical and psychological conditions. Divide the following questions among the group for discussion.

  • Who is most at risk of heat-related morbidity and mortality? How do the social determinants of health affect risk of heat-related morbidity and mortality? What strategies can GPs implement to reduce the risk of heat-related illness among general practice patients? How is climate change projected to increase the burden of heat-related morbidity and mortality in Australia? What is the role of climate mitigation in addressing heat-related illness?

Have each member of the group present a case of a work-related injury.

  • Was the consultation person-centred, with a focus on the patient’s recovery, or was it centred on their desire to return to work or perhaps seeking time off work?
  • Did the treatment plan include elements of what was important to the patient and other relevant parties, and a path for return to work?
  • Did the doctor communicate with the employer and/or insurer? What was the outcome and was it successful? Why/why not?
  • How could you improve next time? What did you learn from others that would change your clinical approach to future cases?
With a friend or family member

Ask a friend or family member about their work and home environments and if they can think of any occupational or environmental hazards: what the hazard is, what the risks are, and what work health and safety prevention mechanisms and policies are in place.

  • What are the health hazards involved in their work and home environments? What actions can they take to reduce these hazards?
  • Are they related to bullying and harassment, either from customers/clients or other team members?
  • What protective mechanisms are there? Are these effective?
  • How does understanding work health and safety preventive mechanisms help you with your clinical practice?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Assess fitness for a new role or renewal of capacity for fitness in a current role:
    • ascertain the expectations of employer and employee and know the job requirements
    • consider a patient’s physical and mental fitness for the tasks required of their role
    • be aware of required alcohol and other drugs screening for a job and have testing facilities available or refer to a nearby collection centre
    • be aware of guidelines that apply to a job; for example, driving standards for commercial drivers
    • refer to other doctors or allied health practitioners, as necessary, for further functional assessments or opinion and management of conditions that may pose a risk to work.
  • Diagnose and treat work-related injuries:
    • assess common work-related musculoskeletal injuries and manage and coordinate care of rehabilitation and return-to-work
    • conduct initial investigations for work-related cancers secondary to exposures in the workplace
    • be familiar with the potential risk of respiratory diseases in the workplace
    • provide initial advice and management for occupational dermatological diseases and refer as necessary
    • understand the potential mental health impacts of work, including workplace bullying, psychiatric injuries and burnout, and be aware of common presentations, such as recurrent absenteeism
    • assess and manage work-related eye injuries, including emergencies.
  • Prepare a worker to return to work:
    • understand how and when to involve a return-to-work coordinator or rehabilitation provider
    • communicate with the employer or insurer about the expected return to work and provide clear instructions on restrictions to duties
    • set realistic expectations for return to duties with the goal of a graduated recovery with minimal setbacks
    • know when and how to refer a patient for assessment of permanent impairment and/or disability
    • know when retraining for a different role is advised
    • understand how the rehabilitation and recovery process may be different in workers who are not employees, where there may be no rehabilitation coordinator or organisational support for returning to work
    • understand the difficulties in rural areas where there is limited access to specialist support, such as occupational health physicians, and identify local networks and upskill as necessary.
  • Have a general awareness of hazards in a patient’s environment, including a changing environment. Patients may be exposed to potential hazards unique to their employment or natural habitat, for example:
    • heat: the effect of environmental temperature impacts infectious diseases, heat-related illnesses and public safety in the context of bushfires. GPs should have access to and respond to public health advice as it pertains to disaster, weather or pandemic warnings.
    • biological hazards: infectious diseases, zoonoses and blood-borne viruses. GPs should be aware of common infectious agents unique to their community of work.
    • chemical hazards: air pollution (including dust, smoke and fumes) and water pollution. GPs should be aware of the common chemical pollutants unique to their community of work.
    • radiation hazards: ionising radiation can lead to several neurological, gastrointestinal, dermatological and malignant processes
    • noise hazards: heavy industry and machinery are unique hazards to workers and local communities. GPs may need to be aware of screening and monitoring for hearing loss in these populations.
  • Appreciate the importance of adaptation and mitigation strategies to reduce the health impacts of climate change for general practice patients in Australia.
  • Appreciate the various ways that climate change increases environmental health risks and population health inequities for general practice patients.
  • Identify patients who will be disproportionately affected by climate-related environmental health risks (eg extreme heat and air pollution) and provide effective support.
  • Appreciate the specific impacts of climate change and environmental degradation on the health and wellbeing of Aboriginal and Torres Strait Islander communities, including cultural determinants of health, and how Indigenous ecological knowledge can inform more sustainable and resilient practice.
  • Understand the role of climate change mitigation through emissions reduction as an effective preventive health strategy.
  • Consider how low-value and unsustainable healthcare practices can be harmful to health at a population level and recognise, and implement where possible, ways to improve healthcare sustainability (eg preventive health, rational prescribing, utilising clean energy).
  • Have an awareness of own working environment as a GP, including hazards and occupational health and safety requirements, and work to mitigate those hazards.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
An introduction to heat-related morbidity and mortality, with a model to guide thinking about prevention of heat‑related disease. The health impacts of climate change and the role of GPs in responding to these impacts.
Online resources
Guidance on improving return-to-work outcomes for ill and injured workers. Position statement to bring public awareness to the important health benefits of work. Describes the role of the GP as patient advocate, care coordinator, treating physician and champion to optimise health outcomes for participants in the workforce. Evidence-based guidelines on managing patients with work-related mental health conditions. The RACGP Climate Change and Health webpage includes policies, resources and the RACGP Position Statement on the impact of climate change on human health. This discussion paper describes climate change in Australia and its impact on the health and wellbeing of Aboriginal and Torres Strait Islander peoples. 
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:
    • This unit gives a framework for managing common work-related injuries.
      • check, unit 567, December 2019: Occupational Health
    •  ​An overview of the incidence of silicosis and how to recognise this condition that has become more common in stone masonry workers in the last decade.
      • Australia's emerging occupational health epidemic: silicosis
    •  ​This considers the investigation and management of conditions related to the environment.
      • check, unit 576, October 2020: Environmental health
Other
A useful resource for how doctors should approach risk assessment for drivers with medical conditions.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/occupational-and-environmental-medicine 12/09/2024