Medical Surveillance: The Role of the Family Physician
Am Fam Physician. 2001 Jun 15;63(12):2339-2340.
Medical surveillance is a term with a variety of synonyms, including medical monitoring. Medical surveillance is designed to detect early adverse health effects associated with certain work duties, such as exposure to occupational hazards.1 It serves as the proverbial safety net in support of primary prevention methods used in occupational settings throughout the world.
For some substances, the Occupational Safety and Health Administration (OSHA) has established standards that require medical surveillance with defined protocols. In cases that lack specific guidelines, standards of practice—as well as the OSHA general duty clause—support the concept of periodic evaluations of employees who are exposed to health risks at work. The “Guide to Clinical Preventive Services” addresses numerous illnesses in terms of the availability and effectiveness of screening measures for prevention; these guidelines may also be valuable in occupational and environmental settings.2
In the context of medical surveillance examinations, a variety of ethical issues may surface. The major potential conflicts involve revenue generation and information transfer.3 Because the components of an evaluation may vary in some settings, depending on the judgment of the physician, opportunities exist to provide questionable services in order to generate reimbursement. A notable example is the OSHA respirator standard. Physicians can use their own discretion to determine the appropriateness of certain ancillary studies, such as pulmonary function testing. For example, a physician may require a host of ancillary tests to approve an employee for respirator use. If the provision of these additional services generates revenue for the physician or the clinic, an obvious conflict may arise.
The other major ethical challenge in the context of medical surveillance is the disposition of medical information following the examination. For example, where is the information stored? For how long? Who has access to the information? What does the employer know? What does the physician tell the patient? Ideally, these questions should be addressed before examinations are performed. In general, the physician is responsible for informing the employer of work-related abnormalities because of the employer's responsibility for providing a safe workplace.4 The employer must recognize occupational health problems and implement appropriate interventions. It is wise, however, for physicians to ask for a signed medical release before the examination so that patients are well aware of the disposition of their medical information. Medical results that have no bearing on the workplace should be kept confidential. The OSHA standards regarding access to medical records provide further guidance on confidentiality.5
In its Code of Ethical Conduct, the American College of Occupational and Environmental Medicine (ACOEM) emphasizes the importance of confidentiality6:
“Keep confidential all medical information, releasing such information only when required by law or overriding public health considerations, or to other physicians according to accepted medical practice or to others at the request of the individual.”
This guideline is particularly appropriate for medical surveillance and other employment-related evaluations. In worker's compensation cases, for example, employers can learn the diagnosis of the condition for which compensation benefits are sought but cannot be informed about ailments with no bearing on the workplace. In all cases, it is wise to inform patients about where their medical information will be stored and who may have access. Recently, the Federal Department of Health and Human Services issued guidelines for the privacy of health-related information that is stored electronically.7
Prevention in medical surveillance is based on the fundamental principle of screening—that is, the administration of a test or tests at an interval such that an asymptomatic condition is recognized sufficiently early in the disease process so that intervention slows, halts or reverses the ailment. Medical surveillance is ideally performed along with a work-site review conducted by an appropriate professional, such as an industrial hygienist. In fact, physicians would be wise to understand the work for which surveillance examinations are conducted. A review of air monitoring data, supplemented by a work-site visit and discussions with plant officials, including labor and management representatives, can be instrumental in understanding the risks that may be present.
Medical surveillance, a fundamental aspect of prevention, can be instrumental in uncovering early signs of occupational illness and in ensuring the safety and integrity of primary prevention.
A shortage of occupational medicine physicians has created opportunities for family practitioners in this specialty of the American Board of Preventive Medicine. The family physician who serves as a medical advisor to a local facility plays a major role in the clinical assessment—the history, physical examination and laboratory studies that are often part of medical surveillance programs. Although family physicians do not customarily participate in the analysis of group data, preliminary review of certain clinical information may indicate trends that warrant further examination.
Family physicians who are interested in this aspect of occupational medical practice are likely to continue to find opportunities to hone their skills.
Robert J. McCunney, M.D., is the director of occupational and environmental medicine at the Massachusetts Institute of Technology, Cambridge.
Address correspondence to Robert J. McCunney, M.D., M.P.H., Massachusetts Institute of Technology Medical Department, 77 Massachusetts Ave., 16-267, Cambridge, MA 02139-4307 (e-mail: firstname.lastname@example.org). Reprints are not available from the author.
1. Harber P, McCunney RJ, Monosson I. Medical surveillance. In: McCunney RJ, ed. A practical approach to occupational and environmental medicine. 2d ed. Boston: Little Brown, 1994:358–75.
2. U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.
3. McCunney RJ, Brandt-Rauf P. Ethical conflict in the private practice of occupational medicine. J Occup Med. 1991;33:80–2.
4. McCunney RJ. Preserving confidentiality in occupational medical practice. Am Fam Physician. 1996;53:1751–6.
5. OSHA Regulations. Access to employee exposure and medical records. Standards—29 CFR 1910. 1020.
6. Teichman RF. ACOEM Code of Ethical Conduct. American College of Occupational and Environmental Medicine. J Occup Environ Med. 1997 Jul; 39(7):614–5.
7. Appelbaum PS. Threats to the confidentiality of medical records—no place to hide. JAMA. 2000;283:795–7.
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