Goldstein, Bernard D. MD
I suggest that the occupational health history taught to current and future primary care practitioners should focus on a second question: “What is the riskiest part of your job?” The lamentably infrequent inclusion of occupational health information in a patient's history is amply documented. Even the simple elicitation of the patient's occupation, the first question in the occupational history, is usually omitted. A recent study of 2050 hospital medical charts found occupation recorded in only 27.8%.1 This is little different from the 24% found in a 1983 study of occupational history-taking by family practice physicians.2
The literature contains many different approaches toward improving the frequency and quality of the occupational history taken by the primary care practitioner. These include better education, the development of compendia of questions that can be self-administered by the patient or used by the physician to follow up on specific symptoms or job titles, and a substantial amount of exhortation.3–12 Inclusion of questions about occupational history in the routine medical evaluation reinforce the importance of workplace health and safety to the patient. But there is little evidence that these approaches have altered the long-term behavior of primary care physicians. One study indicates that physicians' occupational-related questions actually decrease in frequency after institution of a self-administered patient questionnaire.13 It has also been suggested that emphasizing the detailed occupational health history might be counterproductive.14
I argue that those of us involved in occupational health need to rethink our focus on how we facilitate engagement by the primary care practitioner in the occupational health problems of their patients. In doing so, I do not mean to imply that the many educational approaches, questionnaires, and exhortation have been without value—far from it. They have certainly been of service to those physicians interested in occupational health in general, or concerned about a specific patient's problem in relation to the workplace. But workers' health will benefit if we can do better in the competition for the time and interest of the primary care practitioner.
This competition is fierce. The time pressures on physicians, particularly those responsible for primary care, make it increasingly difficult to move beyond a focus on managing the immediate medical problem. The National Ambulatory Medical Care Survey reported that in 2002 the mean duration of a patient's visit with a physician was 18.4 minutes.15 Harber and Merz14 identified inadequate physician time as being as important as inadequate knowledge as a barrier to recognition of occupational disease. This lack of physician time limits the utility of any detailed questionnaire. But there is no question that worker health problems warrant attention and often go unrecognized and unreported.16–19 That occupational health information is of importance to the primary care practitioner has been demonstrated by recent studies reaffirming the impact of the workplace on health.20–22
So what should we do? First, we must reinforce the bedrock need that every patient be asked “What is your job?”
But what should follow that first question? It is unreasonable to expect that the average practicing physician routinely will ask a more detailed set of questions structured around the job. What is needed is a second question that, ideally, should have the following characteristics:
1. Enhance the likelihood that a linkage between an occupational risk and a symptom complex will be identified.
2. Require little of the practitioner's time.
3. Require little detailed knowledge of the workplace.
4. Educate the physician about the workplace.
5. Provide the opportunity for a rapid reinforcement of a workplace health and safety message.
6. Improve physician-patient interaction.
I suggest that the second question should be “What is the riskiest part of your job?”
An ideal question in the context of a physician-patient interaction is one that merely by asking it informs the patient that the subject is of importance. Asking about tobacco or substance abuse sends signals to the patient—and the physician failing to raise the issue is listed by smokers as a reason they continue. Similarly, a question about risk at work informs that occupational risk does exist. Further, the value of asking about job risk as a second question includes what it can do to educate the physician taking the history. Although the patient's response may not be meaningful to their own individual health complaints, the physician may be alerted to the particular risk issue when seeing the next patient with a similar work history. The question also allows the physician to provide a brief occupational health message through a third question emphasizing the importance of avoiding the risk—it can be no more specific than “What are you doing to avoid that risk?” This third question would also help educate both the patient and the physician and send the important message that occupational risk is avoidable.
The second question is a transitional question. It should build a bridge between identifying the job and the more detailed occupational history obtainable through use of the various job-specific or industry-specific questionnaires. It can empower the worker to tell the physician about a risk pertinent to the worker's health problems that might otherwise be overlooked by the physician. The risk issues that may be raised are not restricted to blue-collar workplaces—office workers with carpal tunnel syndrome represent a major preventable worker health problem. Stimulating workers to think about the appropriate answer to these questions might prompt their own evaluation of workplace health and safety issues and their own adherence to good practices. Workers often face new technologies causing unforeseen adverse impacts.23 Talking to the worker may be the quickest way to alert the primary care practitioner to these inevitable changes in risk.
The proposed “second question” also fits well with the growing literature about the importance of empathetic questions as a tool in facilitating physician-patient interactions.24 Fostering empathetic interactions between questioner and patient are central to improving the accuracy, utility, and efficiency of health-related information in the clinical setting. The concept has been applied to physician interaction on issues as diverse as pain management and smoking.25,26 Asking a patient, what is the riskiest part of their job, is a good example of an empathetic question. It remains to be tested whether the second question posed above, or another empathy-based question, is most effective in improving the primary care physician's occupational history.
Obviously, adopting a second question will not by itself solve the problems of occupational health. But there can be little question that our current approaches have failed to achieve a desirable level of interest and involvement in occupational health by the average primary care practitioner. This modest approach of focusing our education of present and future physicians on the second question may take us further toward our goal.
We must continue to insist that physicians ask all patients to identify their job. We also must continue to make available to physicians question lists and interactive approaches that help delve much further into potential job-related causes of poor health or disease. But, given the present habits and time constraints of physicians, a more realistic approach to improving occupational health history taking is to focus on just one more question—What is the riskiest part of your job?
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