Occupational Disease: Addressing the Problem of Under-Diagnosis

T HERE IS WIDESPREAD AGREEMENT AMONG those involved in occupational and public health that work-related diseases are under-recognized. Part of the problem of underrecognition is the failure of physicians and other clinicians to make the diagnosis of an occupational illness. The major strategy to address this issue has focused on training of medical students, residents, and practicing physicians to increase their awareness and knowledge of occupational diseases. (1) Presumably, this will lead to more diagnoses being made. Published studies to date have documented both the significant burden of occupational diseases missed due to the failure to take an occupational history, and the little time spent in medical school curricula on occupational illness. Four hours was the average length of time given to occupational disease in U.S. medical schools in the early 1980s. Repeated study 10 years later showed similar findings. (2) While increasing clinician knowledge may lead to better recognition of occupational disease, this article will argue that a lack of clinician education is not the only obstacle to recognizing occupational disease, nor is it the major obstacle. Lack of training may limit physicians' ability to correctly diagnose and treat, but the economic, political, and social milieu they practice in imposes the more Significant constraints. The evolving current milieu combines new restraints on physician behavior with more traditional influences. As large corporate entities take over the provision of health products and services and care becomes increasingly "managed," for-profit behavior and imperatives come to dominate the health care arena. In the drive to maintain profits while controlling health care costs, health care providers are coming under scrutiny as participants whose behavior needs to be controlled since it is the provider who controls which patient gets what care. The new structures create new opportunities to monitor and discipline providers using criteria heavily influenced by the cost-cutting needs of business. Under these circumstances, it is likely that providers will recognize even less occupational disease than they do now for both formal (for example, pressure to see more patients in less time) and informal (for example, desire of the provider organization to not offend large corporate clients) reasons. The constraints imposed by the corporatized and managed health care landscape reinforce longstanding barriers to diagnosing occupational disease. One set of barriers involves physicians' linking the diagnosis of occupational disease with participation in the Workers' Compensation system. Major disincentives, both financial and non-financial, exist which cause many physicians to make a work-related diagnosis only with great reluctance for fear of being pulled into the Workers' Compensation arena. In addition, physicians may not understand the questions being posed to them by the Compensation system, or they may not appreciate the need injured workers have for the support that Workers' Compensation provides. Another set of barriers stems from the social function and class position of physicians. Physicians' claim as a profession to the exclusive right to define medical knowledge fosters both a professional elitism that questions the validity of non-professional knowledge, and a notion of scientific caution that promotes adherence to the medical mainstream. These knowledge claims are mutually reinforcing with negative attitudes toward workers and labor unions that stem from physicians' class position. This combination of attitudes creates a serious impediment to the recognition of occupational disease. The changes in the health care system along with the more traditional issues outlined above create obstacles that, individually or in combination, are problems requiring