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Environmental and Occupational Health in the Primary Care Setting: Three Key Work-Related Questions to Get the History Right

Clinician examining patient's eyes

Tools and Resources for Clinicians on Environmental and Occupational Health

Silica Standard: 
In 2017, the Occupational Health and Safety Administration (OSHA) released new safety standards for industries that may come in contact with silica. Silica exposure isn’t limited to coal miners and quarry workers. Construction, demolition, and renovation workers are regularly exposed to silica as well. In January 2019, OSHA released an FAQ on the silica standard for general industry, which specifies how medical surveillance should occur for an employee exposed to silica, and which complements the FAQ released last year for the construction industry. Access the FAQs to read about silica exposure rules and medical surveillance requirements:

FAQ for general industry: https://bit.ly/2X14IQL

FAQ for the construction industry: https://bit.ly/2PiQMOn

New Blood Testing for Pesticide Exposure:
Clinical diagnosis and reporting of pesticide exposure is critical for a number of reasons, including to establish trends in exposure, which in turn may have wide influence, from workers’ compensation claims to the federal regulation of a pesticide. However, simple and accessible tools to test and monitor for pesticide exposure may not exist, may not be readily available, or may be too expensive. The May 2018 issue of Biosensors and Bioelectronics detailed a new portable, rapid, and inexpensive blood test that appears to accurately detect biomarkers of organophosphorus pesticide exposure in agricultural workers.1 The test strips were trialed on 124 orchard workers and cotton farmers with long-term exposure to organophosphorus pesticides, and the results were highly accurate.

MCN has long rallied for the Environmental Protection Agency to require that a pesticide manufacturer provide an effective biomarker of exposure to a pesticide in order to register the product. This would aid clinicians in identifying and treating pesticide exposure. This new leap in rapid detection may aid our work as clinicians treating pesticide exposure in the near future.

1 Yang M, Zhao Y, Wang L, et al. Simultaneous detection of dual biomarkers from humans exposed to organophosphorus pesticides by combination of immunochromatographic test strip and ellman assay. Biosensors and Bioelectronics. 2018;104:39-44. doi:10.1016/j.bios.2017.12.029.


Workers’ Compensation and Pesticide Tools:
In the majority of states, clinicians are required to report when a worker has been exposed to a pesticide, but reporting requirements vary from state to state. MCN’s Workers’ Compensation and Pesticide Reporting Map, developed jointly with Farmworker Justice, details state-by-state pesticide reporting regulations, workers’ compensation requirements and restrictions in agriculture, and more. Access the map at: https://bit.ly/2GbhvLc.

Screening Questions for Primary Care:
Use MCN’s EHR-friendly concise and effective environmental/occupational health screening questions for the primary care provider. Access the resource, in English and Spanish, at https://bit.ly/2N2h9Hm.

A hand stuck in the machinery, a fall from a ladder, pesticide drift from a neighboring field. A neurological disorder, black lung, silicosis, chronic kidney disease.  Many patients are at high risk for environmental and occupational injury or illness, both acute and chronic. Construction, agriculture, forestry, and fishing lead the industries with the highest fatality rates, and many of our patients like agricultural workers toil in these industries for at least part of the year. Yet, none of these deaths are truly “accidents”: many deaths even in these high-risk occupations can be prevented with regulations, enforcement, proper training, and safety precautions. 

Clinicians may not be on the job site to provide instruction on appropriate safety measures and workers’ rights, but their interactions with workers in the exam room can save lives. Bringing occupational and environmental medicine into primary care requires diligence on the part of the clinician to build a thorough patient history -- one that may go beyond the electronic health record prompts. Additionally, unlike many illnesses and injuries, the treatment for a work illness such as repeated pesticide exposure and the prevention of occupational injuries are not as straightforward as writing a prescription. Furthermore, with limited time during the patient encounter, clinicians need to assure value in the questions asked. Here are three key areas through which clinicians can uncover occupational risks and injuries, and how to address them during the limited patient encounter.

 

What others jobs might my patient have worked in the last few years?

Many clinicians encounter patients with complex work situations. Multiple jobs in various industries and seasonal, unofficial, or unstable work may be difficult to uncover in a short patient encounter. Maria, who wrote on her intake form that she is a housecleaner, is a typical example. Her asthma had been getting worse, so she went to the doctor at a community health clinic. Her clinician asked, “How long have you been a housecleaner?” Maria said about three months. The clinician reached further back in time: “What was your previous work?” Maria said she was a caretaker for two young children. The clinician moved on and focused on occupational exposures to chemical cleaners. Previously, Maria had worked for six years in agriculture, where she experienced pesticide drift and inhaled dust every summer as tractors and other machinery rolled past the orchards. Maria developed asthma in the orchards as a result of these work exposures. She planned to return to the orchards the following summer, since her caretaking and house cleaning work had slowed. None of this was uncovered during the exam.

Maria’s situation is not uncommon. Most agricultural workers have jobs in other industries when farmwork is unavailable. And, amid the rise of the “gig economy”, work in multiple industries simultaneously or within the last few years has become the norm outside of agriculture as well.

“Work is an important social determinant of health,” emphasized Amy Liebman, MA, Migrant Clinicians Network’s Director of Environmental and Occupational Health. “Understanding what patients do for the overwhelming majority of their waking hours is critical to providing quality care.”

 

How has the industry changed, and how might that affect my patient?

James, a 36-year-old man, arrives at a clinic with a persistent cough, shortness of breath, and chest pain. His intake form shows he is unemployed. His previous work, however, is the key to the diagnosis. He worked for eight years in the coal mines.

In January, PBS’s Frontline ran a half-hour investigative piece on Progressive Massive Fibrosis (PMF), or advanced black lung disease, in the Appalachians, entitled, “Coal’s Deadly Dust.” While the National Institute for Occupational Safety and Health (NIOSH) had officially tallied around 100 cases of PMF over five years, clinicians had been diagnosing significantly higher numbers, with a total of more than 2,000 cases in five states over the same period, many among workers in their 30s and 40s.  NIOSH “had been tracking black lung disease for decades, but they only tested working miners, not those out of work, and hadn’t detected the sharp rise in deadly PMF,” the reporters concluded.

PMF had been falling for decades with the rise of regulation around coal dust, but mining methods had shifted, and the regulations hadn’t kept up, according to Frontline. As areas with deep coal pockets had already been extracted, newer mining operations focused on rock with ribbons of coal, resulting in greater exposure to rock dust -- particularly silica -- than previous generations of miners. (See sidebar for more on silica regulations.)

The continuously evolving landscape of industries may result in changes in the occupational hazards that a worker faces. Other examples include increases in the speed of the conveyor belt at poultry processing facilities, new farm equipment that may increase efficiency but requires new training, and a shift in pesticide application techniques that may increase exposures. 

 

Is my patient mobile, and what does that mean for his or her care plan?

Mobile workers, those who are required to be absent from a permanent place of residence for the purpose of seeking remunerated employment, are at risk for environmental health concerns -- and encounter numerous and overlapping barriers to find and maintain care while on the move. For clinicians, a mobile designation is critical for proper treatment. Thoroughly understanding a patient’s work may reveal the patient’s level of mobility.  Additionally, clinical staff should verbally question patients at every visit to determine mobile status. (See resources for MCN’s screening form.)

Mobile workers, including agricultural workers who move with the season and truck drivers who cross state lines daily, struggle to interact with health systems that were designed for geographically stable patients, and clinicians need to develop a treatment plan that takes the mobile lifestyle into account.  A patient with chronic pain may struggle to get a prescription refilled across state lines at an “out-of-network” location.  A prenatal patient needs regular care even if she is moving every three weeks, requiring a new clinician after every move.  A patient newly diagnosed with diabetes may have to move before completing a nutrition class. For these concerns, clinicians can turn to Health Network, the geographically unbound case management system for mobile patients operated by Migrant Clinicians Network. When a clinician enrolls a patient, a Health Network Associate: contacts the patient directly to establish a relationship, outline health goals, and build rapport; forwards medical records, arranges care, and secures any needed auxiliary services at the next location; and assures that the enrolling clinician receives updates on the progress of the mobile patient. Health Network serves as a critical bridge in the gap that mobile workers face and an important one in treating environmental and occupational health conditions.

 

Health Network and PRAPARE
In 2016, just as PRAPARE was set to launch, Migrant Clinicians Network was beginning to develop its new database to better serve patients enrolled in Health Network, MCN’s bridge case management program. Over the course of the following year, MCN configured the new database to allow for the integration of PRAPARE data, in which one health center’s PRAPARE data can be transferred to the next health center, as a mobile patient moves.
“When we started thinking about that data and [Health Network] case management work, so much of case management isn’t just ‘are you taking your medication every day?’ It’s more about, ‘How can I help you access care and manage your health in general?’” explained Anna Gard, RN, who assisted MCN in the development of the new database. “One piece of this is: ‘Let me help you find a health center.’ But the larger pieces around effective case management are, ‘How are you going to get there? Is there public transportation? How are you going to pick up your medications if you live in a hostile community and you’re afraid of leaving the house?’ PRAPARE gives a structured format to capture [these] data, in a form that’s been tested and validated.”
As more health centers provide case management and chronic care management to address the social determinants of health, Gard noted, integration of the PRAPARE data with Health Network, a virtual case management, seemed to make sense. Now, the Health Network team is working to fit PRAPARE into their own workflow.
Saul Delgado, Health Network Data Specialist, who has been integral in building and launching Health Network’s new case management system, notes that asking such personal questions over the phone, when a patient doesn’t have transferrable PRAPARE data from a previous health center, can be challenging. “When we call, the patient doesn’t know you. They’re very scared to answer these kinds of personal questions, whereas when you go the clinic, you at least see the nurse or case worker face-to-face,” he explained. But he recognizes the utility of the data, and has developed the PRAPARE data screens within the database to be easily accessed from the main patient information screen. With drop-down menus, Health Network Associates can populate the information they hear from patients, like how many people live with them in their household, or if they’re worried about losing their home. The information, either attained from a previous health center or inputted by a Health Network Associate, will be transferred when the mobile patient gets to his or her next destination, just as the basic medical records do.
“Health centers are doing more to integrate social and behavioral determinants of health, and we’re recognizing that all of those things have to be integrated with care management. So we’re on the forefront,” Gard concluded.

MCN Streamline Winter 2019

Read this article in the Spring 2019 issue of Streamline here!

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Authors

Claire

Seda

Director of Communications

MCN