Medical Mismanagement: Should OSHA Dictate How to Practice Occupational Health?
Sandler, Howard M., Occupational Hazards
Before OSHA accuses anyone of medical mismanagement, shouldn't it define its qualifications for passing judgment?
I recently spent four days being deposed by Department of Labor attorneys because I had agreed to serve as an expert for a company facing a much-publicized ergonomics citation. The citation's initial charges included a series of alleged deficiencies falling under OSHA's rubric of "medical mismanagement." Although OSHA has repeatedly promised to stay out of the practice of medicine, this and earlier citations illustrates OSHA's foray into the regulation of occupational health practice.
At a recent National Advisory Committee for Occupational Safety and Health meeting, attendees raised concerns about the apparent lack of quality occupational health care for musculoskeletal disorders (MSDs) and the need for guidance through agencies such as the National Institute for Occupational Safety and Health. Dr. Linda Rosenstock, director of NIOSH, recently announced grant funding availability to train health services researchers in occupational safety and health. NIOSH's stated goals are to improve access to occupational healthcare and the quality and efficiency of that care, and to increase practitioners' participation in preventing workplace injuries and illnesses.
OSHA previously had limited its regulation and enforcement of occupational health practice to medical examination aspects of various chemical exposures for employee placement, monitoring and surveillance, and medical removal in circumstances where potential for exposure existed and actual overexposure or adverse effects of it had occurred. In addition, the concern in many quarters, including OSHA that workplace physical (ergonomic risk) factors may cause or contribute to MSDs has apparently led the agency to carve out new territory for inclusion in its standard setting activities.
Few occupational health professionals (OHPs) would argue that certain musculoskeletal disorders are not work-related to some extent. Certainly, once an MSD is present, various work and nonwork activities may temporarily exacerbate the symptoms and potentially affect the underlying pathology. But there is limited information as to the combination of physical factors and the levels of those factors required to produce or aggravate specific MSDs. The relative contribution of such factors to the development of an MSD also is uncertain. Likewise, we don't know the overall influence of physical factors on MSD development or on MSD-like symptoms. It is this lack of specificity which potentially makes the objective MSD etiology and enforcement of an eventual OSHA ergo/MSD standard difficult.
No one is against making work easier, more productive and safe, but the latter, not the former, is the legislative province of OSHA. In addition, the influence of myriad psychosocial factors increasingly reported to be highly associated with musculoskeletal symptoms precludes the exclusive use of symptoms such as those identified under Bureau of Labor Statistics data or surveillance definitions to identify bona fide MSDs. An exhaustive search for definitions, criteria and scientific basis for identifying and classifying medical mismanagement reveals little of scientific merit. Discussions with former OSHA officials indicate that, while the term "medical mismanagement" has been employed by OSHA, documentation enabling unbiased enforcement by OSHA compliance officers has reportedly not been provided for their use. In fact, that aspect of the citation that I analyzed ultimately was not pursued by OSHA.
Nevertheless, it is critical for all OHPs to become intimately involved in any governmental or consensus standards-setting where professional occupational health care judgment will be judged. It could be as simple as OSHA saying that companies must follow the specific recommendations of qualified OHPs in determining an employee's working status. However, NIOSH and OSHA appear poised to take a much broader role. …