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Role and Value of the Corporate Medical Director

Pawlecki, J., Brent, MD, MMM; Burton, Wayne, N., MD; Christensen, Cherryl, DO, MS; Crighton, K., Andrew, MD; Heron, Richard, MB, ChB, FRCP; Hudson, T., Warner, MD; Hymel, Pamela, A., MD, MPH; Roomes, David, FFOM, FACOEMACOEM Corporate Medical Directors Section Task Force

Journal of Occupational and Environmental Medicine: May 2018 - Volume 60 - Issue 5 - p e215–e226
doi: 10.1097/JOM.0000000000001326
ACOEM Guidance Statement

The role of the corporate medical director (CMD) has evolved over the last 300 years since Ramazzini first identified diseases of Italian workers in the early 1700s. Since then, there has been a gradual blurring of the boundaries between private and workplace health concerns. Today's CMD must have intimate knowledge of their corporation's industry and the businesses that they support, particularly the occupational and environmental programs that comply with all local, state, and/or national standards and regulations. Leading companies not only measure compliance with such standards but also may hold programs to their own internal corporate global standards even if these go beyond local government requirements. This document will explore in greater depth the strength and importance that the CMD brings to the business operations to support a healthy, engaged, and high performing workforce. Part 1 describes the role and value of the CMD, while Part 2 provides collective wisdom for the new CMD from current and past highly experienced CMDs.

American College of Occupational and Environmental Medicine, Elk Grove, Illinois.

Address correspondence to: Marianne Dreger, MA, ACOEM, 25 Northwest Point Blvd, Suite 700, Elk Grove Village, IL 60007 (info@acoem.org).

This position paper was developed by the ACOEM Corporate Medical Directors Section Task Force, reviewed by the ACOEM Committee on Policy, Procedures, and Public Positions, and approved by the ACOEM Board of Directors. ACOEM requires all substantive contributors to its documents to disclose any potential competing interests, which are carefully considered. ACOEM emphasizes that the judgments expressed herein represent the best available evidence at the time of publication and shall be considered the position of ACOEM and not the individual opinions of contributing authors.

The authors declare no conflicts of interest.

The corporate medical director (CMD), also known as the chief medical officer or chief health officer, typically has overall medical responsibility for the company, including all issues related to health (emergency response, critical event management, medical leaves, occupational and environmental health programs, community health interface, and leadership and management of the medical organization). Frequently, the scope of the role extends to include responsibilities within related disciplines such as product stewardship (toxicology) in partnership with research and development, global security (proactive disaster planning), industrial hygiene and safety (biologic monitoring, protective equipment), human resources (HR), and health care benefits design. The company may also look to the CMD to design and implement a global health and well-being strategy working closely with HR, finance, and company leadership, to provide a population health perspective for the corporation.

In most developed countries, including the US, broad health and management experience is highly useful before taking on the role of CMD. Ideally, the candidate should hold an unrestricted license to practice medicine in her or his home headquarters country, although that may not be a requirement in every organization or country. He or she should also achieve board certification, a recognized specialist accreditation in occupational medicine or the more preferred double certification in occupational medicine, and another board such as internal medicine or family medicine. Further qualifications such as a master of public health or masters-level degree in environmental health, business administration, or law are highly desirable, including knowledge of epidemiology, biostatistics, population health management, business management, and regulatory aspects of employee health. CMDs should also remain active in their relevant professional health organizations to demonstrate that they are remaining current in medicine. Before taking on the role of CMD, it is advantageous to have at least 10 or more years of practical experience as an occupational health physician, preferably within a global setting, including at least 5 years in a leadership role managing physicians and other licensed health care professionals.

The role of the CMD has evolved over the last 300 years from Ramazzini's identification and prevention of the diseases of Italian workers in the early 1700s.1 Since then, there has been a gradual blurring of the boundaries between private and workplace health concerns,2 to today's focus on health management for enhanced business performance, health care cost containment, and health-related productivity loss mitigation.3 As the business partnership expectations for medical directors have increased, so has the need to identify the best global providers of care who are able to rapidly identify evidence-based interventions for employee populations, as well as oversee legal regulations, product stewardship, research facilities, and the health of all employees. Finally, the CMD serves as subject matter expert (SME) for any health-related issues that are faced by the employees and their families as well as by the corporation and the communities in which they operate.

Today's CMDs must have intimate knowledge of their corporation's industry and the businesses they support, particularly the occupational and environmental programs that comply with all local, state, and/or national standards and regulations. Leading companies not only measure compliance with such standards but also may hold programs to their own internal corporate global standards even if these go beyond local government requirements.4 Audits may be conducted to assure compliance with legal and regulatory requirements as well as company standards and the results may be reported periodically to senior leadership and other appropriate external stakeholders to keep them informed about potential vulnerabilities.

This document explores in greater depth the strength and importance the CMD brings to the business operations to support a healthy, engaged, and high-performing workforce. Part 1 describes the role and value of the CMD, while Part 2 provides collective wisdom for the new CMD from current and past highly experienced CMDs.

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PART 1: THE ROLE AND VALUE OF THE CORPORATE MEDICAL DIRECTOR

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HEALTH POLICY, STRATEGY, AND LEADERSHIP

The CMD has a major opportunity within the corporate environment to demonstrate the value of a well-developed health policy, a well-executed strategy, and better business outcomes. First, the CMD must understand the corporate mission and its core business including products and/or services. Next, an in-depth understanding of how the corporate medical department specifically supports the business plan is essential. What does success look like in this organization? What are the health and well-being resources currently in place, and are they delivering against expectations? The CMD should determine and clearly articulate a vision of optimal health and business success while efficiently using resources to deliver on this vision. The CMD should be able to engage leadership in this business case, which includes outlining risks of delayed or failed implementation in order to ensure well-informed decisions are made.

Using a variety of data sources – such as HR, health promotion, health and safety, security, medical leaves (eg, workers’ compensation, disability, etc) and potential occupational exposures – the CMD identifies the health risks of the workforce as well as the direct and indirect influencers of health. The corporate medical department should have a mission and vision statement agreed to by senior leaders along with focused priorities. Occasionally, the CMD is required to make decisions which are unpopular with management and/or employees, but that are correct from an ethical standpoint. He or she needs to positively influence the ethics of the organization and seek the support of relevant authorities in adopting and implementing high standards of ethics in the workplace. Ethical guidelines for occupational medicine have been published by the American College of Occupational and Environmental Medicine (ACOEM),5 the Faculty of Occupational Medicine of the Royal College of Physicians,6 and others.7

The CMD should lead the determination of measures of success and how data will be collected using both local and global outcome measures for reporting scorecards. The CMD provides leadership to his or her team who need to align and engage with the other relevant corporate departments such as safety, benefits, HR, legal, facilities, and security. It is critical for the CMD to show the value of investing in health to the corporation by quantifying the cost of life lost, disability-related workdays avoided, and well-being program outcomes, among other measures.

Many corporations study the cost of labor, supplies, and operations when considering expansion of their operations. However, costs incurred from the health of the workforce are frequently an afterthought once the facility is operational. Then, there is a concerted effort to provide wellness programs, ergonomic and prevention programs to address productivity and workers’ compensation issues. It would be more prudent to consider those factors in advance.

Having CMD input into a site selection or acquisition process builds awareness into the process early on and may help influence the location. Knowledge of the local health care system, emergency response, population health, and safety factors may all impact the productivity of the workforce. The CMD can also identify local experts and provide linkages into the health care system. Consultation with the local and national health departments may also assist in providing important knowledge about the population health needs as well as a vital link when critical incidents arise.

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CULTURE OF HEALTH

A “culture of health” has been described as “one in which good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities, guiding public and private decision making; and everyone has the opportunity to make choices that lead to healthy lifestyles.”8 There has been debate over the value of workplace wellness programs. The literature is filled with conflicting studies that measure the value of worksite-based wellness programs and services.9–11 Most experts in the field of health promotion agree that individual stand-alone programs by themselves can do little to address the health risks in a population. On the contrary, a comprehensive approach, including efforts to create a healthy culture with a supportive environment and ongoing strategically designed programs that are refreshed and updated, has been shown to be beneficial for employee health and also for businesses.12–14 A healthy culture enables employers to reduce their health care cost trends and support a high energy, engaged, productive workforce.15

A comprehensive well-being program requires a broadly integrated team approach usually including the CMD, HR, benefits, safety, public affairs and communications, legal, finance, and other stakeholders. Central to the success of a well-being program is leadership alignment and visible support from both senior and middle management as well as worker representative groups such as trade unions. While the goal may be a global program with consistent branding, key messages, and measures, it is critical to understand the individual sites’ health and well-being challenges and target local programs to address their specific needs.

Organizations with happier, more engaged employees have been found to have better business outcomes.16 A key way of creating a culture of health that supports employee well-being as well as a prosperous business environment has been explored through the integration of health protection and health promotion, as in the concept of Total Worker Health®, advocated by the US National Institutes for Occupational Safety and Health (NIOSH).17 By aligning the two missions, organizations are better able to create a culture that focuses on ways to keep workers safe and healthy. When effectively combined in a symbiotic way that increases their impact on the health and productivity of the worker, the whole becomes greater than the sum of the parts. By better coordinating distinct environmental, health and safety policies, and programs into a continuum of activities, employers enhance overall employee health and well-being while preventing work-related injuries and illnesses.18

Companies with highly effective health and productivity programs aimed at developing a culture of health have reported better financial performance than their peers.19–22 Work environments can support health by making the healthy choice the easy choice. The CMD can work collaboratively with dining services, facilities, safety, wellness, and benefits to influence those elements of workplace design that can support the employee value proposition by creating a great place to work. Developing a culture of health within an organization means integrating health improvement within the entire enterprise strategy. Figure 1 depicts the diverse drivers and components that might comprise that strategy.

FIGURE 1

FIGURE 1

Four action areas are shown in the center of Figure 1, which are all focused on the outcome of improved population health, well-being, and equity. Drivers of each action area are listed, along with the pertinent business components. As can be seen in the figure, there are a myriad of business factors contributing to or affected by an improved culture of health within an organization.

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BENEFITS DESIGN

Occupational health often sits siloed in an organization without a link to health benefits, even when both departments reside in the same company division, such as HR. Despite the available expertise of their CMD colleague who is trained in preventive medicine and population health management, many benefits professionals remain reluctant to utilize the CMD's input. The consultation between benefits plan designers and CMD often does not happen organically. The connection needs to be actively cultivated. Ideally, organizations will include occupational health leaders in the global benefits design processes. Having their population health lens to help augment the focus on health care costs and financial instruments (benefits plans) is important for an organization seeking a healthy and high-performing workforce.

The corporation, along with its employees and dependents, is a prime target for population health management through health care benefits design and delivery. CMDs can play the role of a public health officer for their organization, as they are leaders in analyzing, understanding, and managing the health and well-being of the workforce. Occupational health professionals have been on the front lines of the health and productivity movement for many years. More recently, the role of the CMD has expanded beyond preventing and treating work-related injuries and illnesses to include managing the overall health-related issues of the workforce, personal health benefits, and organizational health. This often encompasses elements of health promotion, preventive care, disease management, behavioral health, pharmaceutical management, disability/absence management, HR/benefits management, and health provider contract management. This expanding role is reflected in the transition of terms used to describe the field – from “industrial medicine” to “occupational medicine” to “occupational health” and “corporate health.”23

This transition to corporate health is important, as the incidence of chronic disease is growing at a rapid rate in many countries. Globally, chronic diseases account for 68% of all deaths annually, and this is expected to rise over the next 15 years, while deaths due to other causes are expected to fall slightly.24 This progression of chronic disease is occurring despite the fact that these diseases are largely preventable. CMDs can analyze employee population health data and help design programs that might engage workers in health improvement opportunities to prevent health risks from progressing to chronic disease.

An organization's health strategy should also concentrate on those employees who are healthy to keep them from becoming unhealthy and move those with moderate or high health risks to a lower risk stratification. This is a preferred strategy to contain health care costs in a population rather than primarily focusing on disease management for the sickest in the population.14 However, benefits professionals often rely on “products” sold by their health plan to contain costs in an effort to show the value of a benefits plan design. Disease management programs alone will not sustainably impact the overall health or health care costs for an employee population.25

CMDs can help bridge the gap between workers’ compensation and group health benefits in an organization to better understand the health of the population and incorporate programming that addresses issues that impact both work-related and nonwork-related issues. The share of US workers’ compensation claims with a comorbidity diagnosis nearly tripled from 2000 to 2009, growing from a share of 2.4% to 6.6%.26 Claims with a comorbidity diagnosis have about twice the medical costs of otherwise comparable claims. In summary, companies should leverage the population health management experience of their CMDs. CMDs are highly experienced at working across the many domains of the investment in evidence-based health and well-being services.

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GLOBAL HEALTH, TRAVEL MEDICINE, REMOTE/EXTREME ENVIRONMENTS

Globalization has brought about rapidly changing working conditions that present a challenge to the protection and promotion of employee health and safety. In 2010, there were more than 350,000 fatal occupational accidents worldwide and nearly 2 million fatal work-related diseases, which means about 6300 people die every day from work-related causes.27 While seen by some as a threat to local culture, globalization can lead to improvements in worldwide medical delivery systems and progress in population health. Occupational health has an important role not only to ensure the health of workers but also to contribute positively to productivity, quality of products and services, work motivation, and job satisfaction and thereby to the overall quality of life of individuals and society.28,29

An important consideration when addressing global health is the company's structure and philosophy with regard to how global operations are organized and aligned. How does that philosophy translate into a health strategy and the benefits offerings in all regions? The implementation is influenced by the need to balance both mandated requirements (laws and/or union agreements) and the guidelines related to corporate culture.

Each region and country of the world has its own traditions (or lack of) regarding the practice of occupational medicine. For example, in most industrialized countries, CMD duties are diverse and encompass many facets of employee health – both on and off the job. But in many developing countries, a focus on occupational health is often absent where it is most needed.30

Without careful assessment and action, extreme and remote environments create conditions that may be challenging to employee health. These may include high or low temperatures, radiation, stress, availability of safe food and water, outdoor air quality, health care facilities, or other issues. Characteristics of each individual employee such as age, physical fitness, and lifestyle habits, including sleep and medical conditions, must be considered, as they too affect employee health in a remote or extreme location.

It is also important to assess operational risks. These may include factors in the physical environment, including noise, vibration, stress, radiation, thermal, and ergonomic issues. Potential chemical exposures include toxic chemicals, dusts/mists/fumes, sensitizers, carcinogens, and hydrocarbons. Biologic risks in the extreme or remote environment are wide-ranging, including wildlife endemic diseases (eg, malaria, or yellow fever), and food and water-related diseases (such as typhoid or cholera). The psychological risks to the worker in an extreme or remote environment include issues with isolation, communication problems, cultural difficulties pertaining to local laws, religion or language, leisure and recreational opportunities, substance misuse, and other stressors. These risks often extend to families accompanying expatriate workers. CMDs can evaluate these health issues and prepare the corporation's employees to mitigate such health risks.

As employers have a duty of care for employees who travel on business, CMDs should play a key role in its established policies, implementation, and operations.31 Caring for the health of business travelers is a core role for CMDs who can assess the perceived high-risk locations in which the company operates and the specific risks and threats faced by employees, as they travel to other locations.32 In emergency situations, CMDs work closely with HR and security teams to address the health needs of employees and/or their family.

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ON-SITE CLINICS

The subject of on-site clinics for primary care delivery and/or occupational health care surfaces for virtually all CMDs in a variety of ways. On-site clinics may already exist and a comprehensive review is required. The scope of services may need to be expanded, reduced, or refined. There may be reasons to look at outsourcing the staffing and/or management of the clinic versus providing services in-house. Or, there may be a need to look at near-site clinical services, as well as community partners, in providing services. According to a survey conducted by Mercer, among employers in the US with over 5000 employees, the percent with on-site or near-site clinics has grown from about 24% in 2013 to almost 30% in 2014.33 Aside from convenience, studies have reported decreased absenteeism, improved productivity, and positive reception by employees and employers associated with the on-site clinic.34

It is vitally important to note that the on-site clinic approach should fit into the broader employer health strategy. Health protection and health improvement are the strategic objectives and the clinics are tactics in delivering that strategy. On-site or near-site clinic services in addition to occupational and nonoccupational health care might include wellness, employee assistance programs (EAPs), physical therapy (PT), return to work, disability management, and more. The on-site clinic(s) can offer a variety of occupational and nonoccupational medical services to address the needs and culture of the organization. They may be focused on primary personal care, occupational health, urgent care, or all three. There are pros and cons to each of these options and each of them can work well.35 Corporate health functions must not be viewed simply as “the health services clinic.” The current role of the corporate health function emphasizes the value of the clinic, beyond the services provided by the physician, nurse practitioner/physician assistant, and clinic nurse functions.

The CMD must understand and the company must be in compliance with a wide variety of country, state, county, city, provincial, and other regulations related to on-site clinics. This complex area requires knowledgeable legal, regulatory, licensing, and taxation expertise – for example, some countries require a defined medical staffing level based on the number of employees, while others may also define the scope of services provided at the workplace. The budget for the on-site clinic also requires careful planning and expertise. Planning must ensure that the clinic is operating within the context of the benefit and tax laws as well as in coordination with the other health plan offerings.

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EMERGENCY PREPAREDNESS

The CMD has another important role that requires much preparation and testing: emergency preparedness. Unfortunately, critical incidents occurring within or impacting worksites are all too common. The CMD is a credible SME regarding health and medicine and, as a trained physician, provides critical medical expertise during an emergency and in implementing prepared plans.

Business continuity planning for critical events is a core activity for all corporations. A range of possible scenarios with variable impacts are modeled and mitigation appropriate to the threat is then developed. Few risks are considered material enough to make it onto the corporation's group risk register. Most business continuity threats may be mitigated at a local/site/plant level. However, health threats such as global pandemics or localized large outbreaks of infectious disease do have the potential to disrupt business on a global scale, and as such, detailed planning is required. The modeling of table-top scenarios and practice drills are part of an integrated risk analysis. At a minimum, each major work-site and the company overall should know the principal threats, which they consider most likely to occur and have corresponding critical event plans.

The global CMD needs to be prepared to deal with periodic communicable disease outbreaks such as TB or measles, as well as other health threats.36 In the case of an emergency critical event such as a pandemic influenza outbreak, the CMD can decide which published or internal emergency phase approach to use,37 and participate in the incident command role and system. It should be stressed that even with exhaustive planning, critical events seldom play out exactly as predicted, so planning and frameworks for response and leadership actions must be flexible if they are to be successful.

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EXECUTIVE HEALTH

The concept of offering executive physical examinations dates back to the early 1900s when companies responded to a growing body of medical knowledge that supported periodic health evaluations to reduce mortality. Increasing numbers of employers offered these examinations to their management teams to identify medical problems and improve health, productivity, and longevity.38

Executives within a corporation frequently have intense schedules with long hours and demanding business travel schedules. Given this, many companies have designed and offered executive health programs to address the health and well-being of these key corporate assets. The examinations may include primary prevention in medical care, while providing an efficient means for health education, increasing the potential for preventing disease or identifying problems early, and encouraging a healthier lifestyle.

In some cases, a vendor is selected to deliver the executive health examinations. In other situations, the choice is made to deliver them by medical personnel in-house. In either situation, the results remain strictly confidential. In recent years, the idea of offering preferential examinations to executives has both advocates and opponents. Some companies have discontinued these examinations for financial or philosophical reasons, as providing additional or different benefits to executives than is offered for the majority of employees is counter to their culture. In addition, there are concerns of the overuse of testing in these programs that may have questionable value or even potential harm from additional testing. In some companies, preventive examinations are covered for all employees as an essential benefit in health plans.

CMDs who oversee an executive health program have a unique opportunity to showcase the importance of health and how it relates to productivity. Rather than these examinations being a perk, the interaction can foster close access to senior leaders who can help support the many programs that are a part of the health strategy. The examination process can serve as a time to update travel vaccinations and to identify behavioral health or personal issues that could interfere with the executive's overall health or performance. It can also serve as a reminder to the executive to keep employee health in mind when making decisions that impact corporate operations.

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MENTAL HEALTH

Mental health disorders represent one of the most common health problems of workers globally and is an area CMDs deal with on a frequent basis. The World Health Organization predicts depression will be the top cause of disability globally by 2030. As mental health disorders have a peak onset of incidence in the working age population, CMDs have a unique ability to address the unmet needs of this population. Mental health and substance abuse (MH/SA) conditions are often underdiagnosed and under-treated resulting in avoidable mental costs, absenteeism, disability, and lost on-the-job productivity (presenteeism). The investment in mental health treatment services globally has been lagging.39–42

For the best outcomes, workplace interventions should be integrated by the CMD and include strategies to reduce work-related risk factors for behavioral health problems; promote mental health awareness and available resources; and address mental health problems regardless of the cause.43 Given the widespread effects and influence of these disorders on worker performance/productivity, the CMD can address MH/SA with multiple points of impact in the workplace. These areas include benefit plan design, EAP offerings, disability management, employee/manager education, and data collection, management, and analysis.44,45

The workplace is an important location for interventions aimed at preventing the development of and providing assistance to those employees suffering from depressive disorders. A number of studies have demonstrated the value of worksite programs to decrease the risk of mental health disorders such as depression and stress.46–51 There have also been several reports of successful workplace MH/SA interventions.52–55

Stress is one of the most frequent health risks cited by employees who respond to health risk appraisals (HRAs) globally. However, the sources of stress vary greatly between individuals and from country to country. Stressors may include the job, but frequently include factors outside work, such as financial, interpersonal/family relationships, health conditions, etc.

In general, an HRA that includes self-reported questions on MH/SA as well as productivity questions (absenteeism, presenteeism/performance) is most useful to determine the economic burden of MH/SA disorders in a global organization. The reason is that for most foreign countries, medical and pharmaceutical cost data are not available. Research has demonstrated that depression and stress as identified on HRAs, account for major economic losses in the workplace including lost productivity/performance.56,57

The CMD has a natural leadership role to play in an employer's response to the human and economic costs incurred as a result of MH/SA disorders.44 In partnership with other departments/functions, including EAP, benefits, work/life, health promotion, HR, employee relations, security, etc, the CMD can initiate and contribute to company programs, policies, and services that decrease the direct and indirect costs associated with MH/SA disorders.

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HEALTH AND PRODUCTIVITY

There has been a growing awareness of the major contribution of workers’ health to their productivity. The CMD has the ability to understand and guide the data analysis of the linkages between worker health and the economic impact of lost productivity on an organization. However, reductions in worker productivity due to health-related problems are an indirect cost to corporations and society that is largely unmeasured. Absenteeism, disability time off work, and impaired on-the-job productivity (also termed “presenteeism”) costs are significant contributors to an incomplete estimate of the total loss of productivity resulting from impaired health.

Lost productivity related to absences associated with sick days and incidental absences is usually limited and either not tracked or poorly tracked by most organizations. The relationship between productivity and health, both medical and psychological, is largely underappreciated. Employees with various chronic medical conditions, such as asthma, diabetes, depression, migraine headache, and arthritis, experience brief episodes of absenteeism that do not lead to more extended short-term disability (STD) absences, and, therefore, their impact on lost productivity is underestimated by most organizations. However, engaging such employees with chronic medical conditions in appropriate disease management programs has been shown to improve on-the-job productivity and reduce the likelihood of absenteeism.58–60

STD benefits are salary continuation income for workers, which generally begin after a defined number of consecutive workdays off for illness or injury. Comprehensive management of workers’ compensation losses includes prevention by identification of potential workplace hazards, early provision of appropriate medical services and flexible return to work from a work-related illness or injury. Thus, safety is an important component of a total workplace health and productivity management program directed by the CMD in partnership with other groups, and as part of the broader employee health strategy of the organization. It is well documented that when safety is a high priority in an organization, the accident rates typically decline dramatically.61–65

Presenteeism is the reduction in a worker's on-the-job productivity because of acute illness, injury, chronic medical condition, or a variety of other factors including caregiving for others. Several studies have shown the association between health risks and presenteeism.66–68 Cohorts of employees have been followed over time and results found that employees who reduced their number of health risks also showed an improvement in their productivity.69,70 On the contrary, employees whose number of health risks increased, in general, had lower on-the-job productivity/performance. Several estimates have indicated the costs of presenteeism may greatly exceed the costs related to absenteeism and disability for an organization.71,72 Carefully designed workplace wellness programs have been shown to impact these costs by addressing health risks and medical conditions.

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CONCLUSION

The role of the CMD is to manage a broad spectrum of potential health, social, and environmental challenges with in-house standards, policies, and directives as well as the ability to identify best-in-class programs and providers. Business leadership expects a rapid response to manage critical issues related to employee health, product protection/stewardship, public relations, legal, and regulatory compliance. They also rely on the CMD to ensure critical response arrangements are in place and that anticipated disaster management plans are successfully practiced and documented.

The expansive roles of the CMD can be key to maintaining and enhancing not only occupational health but also personal and organizational health and well-being of employees. In doing so, improved employee morale, enthusiastic leadership involvement, and encouragement often leads to significant gains in employee engagement and business partnership/productivity. The role of CMD demands a rare combination of business and health insight, technical proficiency, as well as agility for rapid situational assessment and response on a daily basis. The role-holder must have an in-depth understanding of the business context, strategy, and challenges so the design and delivery of world class health and wellness programs can proactively target opportunities, and therefore be a source of distinct competitive advantage.

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PART II: ADVICE FOR THE NEW CORPORATE MEDICAL DIRECTOR

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INTRODUCTION

In Part I, the expansive role of the CMD was described and the value of that position established. The CMD may manage one or more areas for a corporation, including health policy, benefits, global health, critical incident preparedness, on-site clinics, and employee health, wellness, and productivity, among others. Given the wide-reaching areas that a CMD should have competence in, we have compiled advice from eight CMDs with a combined experience of more than 200 years in the field. We hope that this advice will be invaluable to anyone just starting out in their role in corporate medicine, but likely has value for even the most experienced CMD. It can also be valuable for companies evaluating how a CMD may fit within their organization. CMDs take on a management role within the company, often without prior business experience. Being a good clinician does not automatically mean you will be a great manager or leader. Therefore, we would like to identify and describe the key activities and behaviors that lead to success in the role of CMD.

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KNOW YOUR SKILLS AND LIMITATIONS

In our experience, the best CMDs have abilities in the key areas of leadership, strategic planning, finance, and networking. If you recognize gaps in your skills or knowledge, seek out ways to learn them or develop them, recognizing that many of these skills are cultivated with experience. Some specific skills experience that will greatly benefit your abilities in your organization include:

  • auditing occupational health programs for quality and effectiveness;
  • designing and interpreting epidemiologic health studies;
  • developing medical solutions, including implementation of on-site clinics and managing relationships with off-site vendors in the US and internationally;
  • understanding state-of-the-art evidence-based medicine, clinical research, public health studies, and their relevance to company operations;
  • collaborating with business leaders in legal, employee relations, security, facilities, and HR to assure the protection of the health of the workforce;
  • leading a corporate team and providing leadership to the business globally.

Personal attributes that will also serve the CMD include outstanding written, verbal, and presentation skills. The ability to be a powerful communicator and creative presenter to both clinical and nonclinical groups is key. The CMD will have to “sell” his or her initiatives to the organization, so it helps to have strong influencing skills and the ability to create buy-in as well as excellent negotiation skills.

As a problem solver with a track record of success, the CMD is seen as professional in his or her approach and demeanor with a strong executive presence. Try to remain enthusiastic, self-motivated, and high energy and share your passion for quality health care at the most cost-effective level. Always maintain a high degree of professionalism and integrity, while embracing the entrepreneurial spirit and willingness to get the work done. Remember, others observe and notice your words and actions, as you are a respected leader of your organization.

Develop your ability to make complex decisions, gleaning understanding from whatever data are available, with a quick study of things that are new and different. Add your personal wisdom and experience to achieve the best solution given the situation using multiple problem-solving tools and techniques. Be open to lifelong, continuous personal improvement, and be responsive to feedback from others so you can strengthen any weak areas.

Be strong in your knowledge base and keep current on developing trends and research in the field. You are generally one of the few people in your organization with knowledge of the health risks and concerns for the employees – who may also be known as your patients. It is critical that you know your limitations and when it is important to bring in experts from complementary fields.

A healthy organization owns up to its errors and learns from them. The same should apply to the CMD. Bring them forward to your senior leaders, along with lessons learned and plans about how to improve in the future. This approach shows the CMD's honesty, humility, and commitment to the organization's success.

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KNOW YOUR ORGANIZATION

Of critical importance to your success as a CMD is how well you know the organization in which you work and the products or services that are produced – its purpose. Make it your mission, early in your career, to identify the organizational culture and key influencers, processes, risks, customers and employees, lifecycle of the product, and other factors critical to the success of your organization.

A good way to begin this education is by reviewing current and past annual shareholder reports, the intranet website, and by searching the internet for current and past articles about the organization. This is best done before you interview for the position. After receiving the appointment, attend the annual shareholder meeting, and listen to the presentations by the chair and other leaders who can provide insights into the business. It is more important for you to hear others than it is for you to be heard. There is often a “must-read” book to help you understand the nature of the corporation's business – get it, read it, and use it. Carefully review the company's mission and vision statements, which clearly communicate the goals of the organization. Use these statements as a basis for the mission and vision statements for your department.73

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KNOW YOUR POSITION

An unusual aspect of the CMD compared with the medical field in general is that you are not the most important person in the room. Vice presidents, senior VPs, presidents, and CEOs will all outrank you; therefore, get an experienced business mentor to help you navigate internal politics and decision-making practices. While your technical knowledge will likely be accepted (that is why you were hired), your capability to make wise decisions and gain support from the right people in a new organization can be difficult.

You may be absolutely correct about a certain issue, but due to business needs, another path may be chosen. You need to become comfortable with that and realize that the leaders synthesize your input along with many others’ in order to balance what they see as best for the business. When you are consistently not comfortable with those decisions, it may be time to reflect on whether another organization might be a better fit for you. While you are valued for your subject matter expertise, it is essential that you are able to make a coherent business case to secure the investments necessary to fulfil your mission. The ability to clearly and succinctly articulate your business case/request is critically important in communicating with senior executives. The one-page memo is an excellent tool you can develop and utilize. It includes these components74:

  • Introduce your idea – describe your proposal in one sentence;
  • Perspective – provide context, trends, and situational issues;
  • Explain how your idea works – how, what, who, when, where;
  • Reinforce its key benefits – give the three most important benefits of your proposal (from the audience's perspective);
  • Suggest the next step – a call to action: who needs to do what by when in order to move forward.

To be successful within your organization, you need to be seen as a value-adding business partner and not just as necessary but expensive overhead. If you are not deemed credible and pragmatic, advice or services may be sought from other less competent sources. Do not forget, you are there to support the business operations. If not for that, you do not have a role at that company. In light of that, be sure to take care of your boss. Know what is needed to help your senior leaders succeed and avoid getting involved in politics. Identifying and implementing quick wins that solve problems or meet needs is helpful. However, the successful CMD is also patient; the best time to implement a solution that you and your team can see as necessary may need to wait for the right time within the business.75

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KNOW YOUR CUSTOMER

Occupational health means many things to many people and it is important to know your customer at all times. First, the CMD meets the needs of individual employees.73 For someone who is offered a job at your organization, the CMD provides health assessment screening and determines whether or not a person can perform a specific job safely, particularly considering any health issue or disabilities they may have. Employees who are exposed to hazards at work are provided with education, training, and health surveillance. For individuals who are at risk for a communicable disease, such as business travelers and health care workers, CMDs provide immunizations, education, and medications. Employees with work-related or nonwork-related health conditions are supported with workplace adjustments or suitable alternative work. Finally, all employees are provided with health promotion in an effort to improve or maintain a healthy lifestyle and therefore, optimal health.

CMDs and the occupational health department also meet the needs of the employer in many diverse ways. Legally required health surveillance programs must be implemented and managed properly by the CMD. Health and wellness programs are designed to reduce lifestyle health risks that are often associated with sickness absence or reduced productivity. The CMD helps craft policies, practices, and cultures that improve the company reputation and develop contingency plans to deal with health risks, which may impact the business process such as emergency situations, disasters, and pandemics.

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BE A LEADER

Leadership is different from managing. Many of the skills learned during medical training can and have been used successfully in leadership. We bring credibility to the role based on our degree and training; however, this is only the starting point, as we shed the white coat and stethoscope and become a leader in the corporate environment. Build trust and show competence as the internal SME and then expand to your direct working group. Find mentors outside your area of expertise that are more involved with business success. Use these mentors to discuss issues and review your presentations so they are effective in the business.

Do not be afraid to lose the SME title, as great leaders develop and bring in individuals with better or different skill sets. Working with others whom you would not normally interact is a way to broaden your knowledge while gaining recognition in the organization. Actively seek out and take on roles that are outside of your comfort zone. Leaders work to make their staff better each and every day. Pay close attention to your staff and give them development opportunities. Make sure your team members are seen within other areas of your company – recognize their contributions in front of others. If your team is poorly functioning, it will limit your advancement. Do not be afraid of hiring people with stronger or complementary strengths to your own. As you advance up the corporate ladder, your performance will be judged by the success of your team. The effective CMD inspires and engages a team and manages people well. Getting the most out of his or her teams includes setting and communicating goals, measuring accomplishments (scorecards, work, and development plans), holding people accountable, and giving useful feedback. They are also not afraid to change out poor performance if improvement is not forthcoming. It is not easy to delegate but also stay informed, while providing coaching for today and the future.

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BUILD YOUR NETWORK (INTERNALLY AND EXTERNALLY)

No person is an island and no CMD succeeds alone. Network ferociously and create a web of contacts. Your network is your most valuable asset because almost every situation you encounter will have been seen before by one of your colleagues. Some ways in which this might be accomplished include:

  • Attending key national and international conferences such as American Occupational Health Conference (AOHC), International Commission on Health (ICOH) and other occupational medicine meetings.
  • Subscribing to CDC and WHO updates.
  • Getting to know the key players in the field. (Who is publishing? Who is presenting at conferences?)
  • Understanding key occupational medicine products and services.

This process of developing a network allows us to reach out to these relationships when we have a need. Another valuable strategy is to develop relationships with the local ministries of health and health departments in countries that impact business and local employees. This is often best achieved by developing your own “in-country” contacts. Participate in external organizations such as the Global Business Group on Health, your regional business group on health, and local business coalitions to learn how leading corporations are driving innovation.

Do not neglect the internal network within your organization, either. Develop your “one minute” elevator talk about what you do and how you can assist others within the organization in a quick, compelling value proposition.76 It typically includes:

  1. Making a connection with the listener and identifying the problem;
  2. Your specific solution;
  3. Differentiation;
  4. What you need.

Know where to go to get what you need. Remain politically aware and agile. Your internal network will help expand your exposure and is helpful to understand changes that may occur.

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STAY UP TO DATE, BUT DELEGATE

Stay on top of the business priorities at your organization. The more your priorities align with the business priorities, the more likely you are to receive support for your proposals. This also helps your team see how their work matters to the organization as a whole. In a large or international organization, it may be impossible to stay abreast of every region or multiple countries because things are continually changing. Thus, it is important to employ a competent local staff, then increase their training in particular aspects of population health or in special focus areas. Local staff, particularly in international organizations, provide the cultural awareness and sensitivity for the corporation to manage at the local level. Do not pretend to be an expert in all things, but make sure you know where to go for the information you need.

There are no “gold standard” global health measurement tools for occupational medicine because each multinational organization determines what it values and measures. One fairly consistent measure utilizes workplace injuries. This can be a good place to begin for companies that are considering gathering global metrics. A compilation of available local metrics can become another measure. For example, it is helpful to know the percentage of employees with medical care benefit coverage, the percentage with access to EAPs and mental health counseling, the percentage with access to HRA and the findings from those surveys, and the percentage of employees who use tobacco and/or the number who are located in smoke-free facilities. Many companies also utilize engagement surveys that may include health, wellness or well-being, and stress questions. Another helpful tool can be the adaptation of the Worksite Health Scorecard from the Centers for Disease Control.77 Capture the recommendations of the trusted and credible sources such as the CDC, WHO, International Labor Organization, European Agency for Safety and Health at Work, ICOH, Occupational Safety and Health Administration, or the Global Business Group on Health. Build onto the guidance of these resources and personalize it to fit the needs of the population you serve.

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CONTRIBUTE TO THE BUSINESS AND THE FIELD

If you stay closely aligned with the business strategy, it will be easier to demonstrate a direct relationship between your work and the competitive advantage (the bottom line). Moreover, identify something you enjoy or a particular issue that needs to be addressed and take it on. Do research, identify solutions, increase awareness, and ultimately, make a difference. Seek out research partners in higher education or in government with whom you can accomplish these tasks. Learn what health and productivity databases are available to you (or begin collecting the information yourself) and identify the metrics that are most important to your leadership. Examples might include HRA, absenteeism, productivity, health care costs, hospitalizations, or workplace injuries. Seek out benchmarking data with which to compare your population. Develop outcomes measures for the major services you provide. Wherever possible, develop return on investment/value of investment metrics.

Make time for yourself and your family. While you may work for several employers, your family relationships will last your lifetime. Be a positive example to others with your good health habits and work-life balance.

Every doctor has been to medical school but not every doctor gets to work in industry. In your career as a CMD, you will acquire new skills and knowledge that make you a better practitioner. Importantly, you have unique access to a vital sector of the population, and as such, the opportunity to influence and shape outcomes that may have a profoundly positive impact on communities and the broader society. Passing on this information is important to maintaining a position of influence. Continually look for opportunities to innovate and then share those improvements with the organization and colleagues.

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GAIN TRUST

Obtaining the trust of employees and leaders within the corporation is crucial to the CMD's ability to conduct his or her work effectively. Corporate leaders will scrutinize the financial and legal aspects of the CMD's decisions and may limit physicians’ freedom to conduct testing, treatment, or information dissemination. Because the CMD is both clinician and leader, he or she must serve two groups: the employee patients and the managerial goals such as bolstering the corporation's public image, reducing the threat of lawsuits, and setting corporate policies regarding hiring, firing, and safety issues.

Employees may be skeptical of the CMD and corporation. CMDs can gain trust through their words and actions and by preserving the physician-patient privilege and maintaining strict confidentiality of medical records and information. An effective trust-building strategy is to create a personal connection with employees. Get to know the people in your organization and let them get to know you. As much as possible, be transparent and truthful, even if you are the bearer of bad news. Motivate through encouragement, as many people are not motivated by being given orders. Identify the shared values that are common to the employer and employees. When employees believe the goals of the company are aligned with their personal goals, they are more likely to engage in your programs and services. Finally, follow through on commitments and stay up-to-date on your own continuing education.

At times, you may be encouraged to compromise your ethical standards either for the perceived benefit of the company or for a particular individual. Alternatively, you will be required to make decisions that are unpopular with your organization or its employees but that are correct from an ethical standpoint. Remember, trust is hard won and can be lost in an instant. Maintain the highest standards of ethics and frequently review the guidelines published by the relevant organizations in the field.5–7

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MAINTAIN CLINICAL COMPETENCY

First and foremost, you must know medicine and keep current on developing trends and research in the field. Many CMDs remain directly engaged in patient care, either in their worksite clinic or in a standard private practice. The 2013 Physician Executive Compensation Survey,78 published by Cejka Executive Search and the American College of Physician Executives, found that 69% of CMD respondents continued to practice medicine, and 56% reported that maintaining clinical hours was a job requirement. Clinical work can be an important part of the CMD career because it is likely not only something you find enjoyable and rewarding but also provides a chance to work on the front line directly with patients. It provides credibility both within your corporation and among your fellow physician colleagues.

If a primary care and/or occupational health clinic is already in place at your organization, the wise CMD is always prepared with data such as volume of visits; types of clinical visits and issues addressed; level of visits; nonclinic visit work, such as answering clinical and program queries and producing reports, establishing policies and procedures for clinics; and nonclinic work sponsored via the clinic such as vaccines, wellness, biometric or other health campaigns, patient and customer satisfaction, including understanding the business and job tasks themselves to better understand mechanisms of injury and so better address prevention; time saved cycle time compared with going off site for injuries and examinations; success at return to work; staffing head count; and of course, cost comparisons with community alternatives.

At some point, it is not unusual to examine whether it makes more sense to hire an on-site clinic staffing/ management company to outsource functions, requesting appropriate vendors for information (RFI) and then proposals (RFP). Capturing the time, cost, results and satisfaction of vendor management against expectations must become part of the calculus of the “return on investment” (ROI) in the outsourced model, as the challenges can be considerable in making any model run smoothly either in sourced or vendor managed clinic activities.

Addressing the ROI and value of the investment (VOI) is a recurring theme that must highlight the above areas and should include addressing liability concerns such as confidentiality, malpractice, corporate practice of medicine in some states, regulatory issues of ERISA, taxation of benefits like the wellness and clinic services themselves, and taxation of other benefits.79 Some employers may select a hybrid model of insourced and outsourced clinics, near site clinics, and community partners. Finally, regardless of the model, how the clinic fits into the overall health strategy is critical; leveraging clinic assets to tie into wellness, EAP, safety, and business needs are keys to success.

While physician, nurse practitioner, physician assistant, registered nurse, and administrative clinic staffing models have been published by the Association of Occupational Health Professionals in Healthcare and others, these models may not be accepted by HR and business leaders. The type of business, such as manufacturing, financial services, chemical, and other industries, may require tailored staffing models. In addition, the scope of services proposed, the budget available, the planned number of employees, governmental regulations, and other factors will impact staffing levels. The level of medical expertise, specialized expertise, and programs such as toxicology, spirometry, audiometry, x-rays, lab, phlebotomy, and many other aspects of staffing must also be considered.

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STAY ON TOP OF EMERGING PRIORITIES

Mental health issues, whether fully recognized or not, play a significant challenge for organizations. The CMD plays an important role in evaluating the issues that arise, while balancing the needs of the individual and the organization. The failure to deal with mental health globally is attributable to several reasons, such as skepticism in some countries about the accuracy of mental health prevalence data, questions on the efficacy and availability of treatment resources especially in underdeveloped countries, cultural issues that undermine seeking treatment and the stigmatization of those with mental health disorders, prioritization for communicable disease funding versus funding for mental health disorders, among others.

EAPs have been provided by employers in the US for over 50 years and more recently globally. A number of models have been used, including totally in-house counselors, totally external services provided by a vendor and hybrid models using a combination of on-site counseling services and vendor-provided services. Although widely offered, there have been relatively few studies showing the benefits of such programs.80,81

MH/SA disorders are frequently the primary cause of disability and not infrequently a comorbid condition in disability events such as diabetes, heart disease, and other chronic health conditions. The CMD can align a variety of resources to support these employees and thereby reduce the impact of lost productivity on the organization. Corporations have recognized that if employees do not have access to appropriate mental health treatment, the result can be lost on-the-job productivity/performance, short-term and long-term disability, and avoidable medical costs. Frequently, mental health disorders are misdiagnosed as medical problems (eg, chest pain caused by stress/anxiety/panic disorders) or are comorbid conditions with chronic medical conditions (eg, heart disease, diabetes, cancer, etc).

MH/SA stigma is considered a major reason why employees do not seek assistance for these conditions. A number of companies have successfully addressed stigma through employee/manager/supervisor training and education, program branding, marketing, and other initiatives. In addition, the placement of mental health counselors in on-site clinics has been found to be effective. Presentations by senior leaders who have personally benefited from MH/SA treatment or who have found the benefits of such treatment for individuals in their organizations has been used to address stigma. Such campaigns have included “Stand Up for Mental Health,”82 and “I Will Listen,”83 among others provided by mental health organizations.

Managers and supervisors can play a key role in the early identification of a troubled employee including those exhibiting signs or symptoms of MH/SA. Employer policies and training can help managers or supervisors intervene before problems lead to significant job performance issues and disability. Such training can be a cooperative effort between the CMD and EAP. Although it is important that managers or supervisors are familiar with their role in the detection and management of MH/SA disorders at an early stage, they should be instructed not to diagnose the problem but rather recognize the patterns of job performance problems and then intervene with the EAP or occupational health department.84

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THINK GLOBALLY AND IMPLEMENT LOCALLY

Multinational corporations often operate with a mixture of global policies and standards while accommodating local legislative requirements within their management systems. The maturity of the occupational health provision varies widely from country to country with less well-developed regions focusing largely on primary care provision and the more mature regions engaging in a range of primary, secondary, and tertiary interventions. The CMD is required to navigate and interpret the disparate health systems and requirements of the countries in which the business operates. A particular challenge comes with drafting and implementing corporate occupational health standards globally that, while they may be significantly more stringent than those expected in some regions, serve to protect and enhance the well-being of the workforce without being so onerous as to be impracticable. Fundamental to any organization's license to operate is the requirement to implement effective risk management. It is essential that the CMD leads the development and implementation of robust quality assurance mechanisms with respect to the occupational health elements of the overall management system.

Monitoring of the myriad of regulations that develop from international, national, and local bodies is a challenge for global organizations.85 The CMD provides an important perspective navigating the intent of the stated rules with the knowledge of the corporate operations and the impact on the employees and surrounding communities. It is essential that CMDs develop and maintain global networks of physicians familiar with the content and context of local health expectations in order to advise the corporation appropriately. Compliance with regulation is not just “checking the box,” as unintended consequences may result without careful consideration of the many impacted components.

In order to effectively communicate health information to a global audience, the CMD must first identify the communication channels that exist in each region and the targeted audience. Recognize that communication across the globe is not simply a matter of translation as it must be culturally appropriate, including wording, references, photos, and graphs. In global communication, tying the local messaging into the overarching goals of the company is the most effective strategy.

Examples of recent global health events that had the potential to disrupt corporate activities include the avian flu, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome Coronavirus (MERS CoV), Ebola, and Zika. The CMD must be aware of travel alerts, country risk level, and guidance. In the past year, there have been approximately 6500 travel advisories issued by a variety of global health security organizations. The risks for employees who travel may arise with the process of travel, through the risks of the traveler being in an unfamiliar environment, or from the exacerbation of a pre-existing medical illness that occurs during the trip.

Employees who travel have varying levels of sophistication of knowledge and comfort, and may be called on to travel to attend meetings or trainings for projects and benchmarking, or longer term assignments that may include an expatriate assignment. In the most extreme cases, employees are sent to explore uncharted areas for development of procurement relationships or for future facilities and operations.

Known and unforeseen infections pose huge risks for travelers and the CMD should align the preparations for preventing illness before travel through immunizations and medications appropriate for the risks encountered with each location, and the proper follow-up necessary upon return.86 The numerous infectious risks (22% to 64% of travelers report some illness87,88) are continually changing and require diligent monitoring of the expert resources to prevent potentially fatal illnesses. Additional CMD expertise is required to minimize and manage the stresses that occur with jet lag, blood clots, meals, and the extremely common travelers’ diarrhea.

Beyond infections, travelers may experience road accidents, opportunistic crime, political unrest, natural disasters, or even work-related injuries or illnesses that require the contacts and navigation of an unfamiliar health system by the CMD. Often overlooked is the risk for anxiety and depression in the traveler, while away from family and routine. This may lead to high-risk sexual activity and/or substance use. In addition, travelers often tack on excursions that may include high-risk or adventure travel, placing them at significantly increased injury and illness risk unforeseen by the company.

The decision for an expatriate assignment presents the perfect, yet often overlooked, opportunity for the CMD to identify health and emotional risks that may be present or exacerbated during a foreign assignment. The confidential relationship between the traveler and family members and the physician can aid assessment of the medical conditions present and the ability to obtain needed medications, treatments, and follow-up care. The CMD can help assess whether this person and the family members should even be going on assignment, as the risk of an expensive failed assignment could be more likely to occur.

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FINAL THOUGHTS

Each day ask yourself, “How is my department contributing to the health, well-being and productivity of the workforce, and the bottom line of the corporation?” And, “What are my specific measurable results to prove it?” Your value proposition should communicate the unique abilities of occupational health and how they add value to the company's business. The expansive role of CMD can be the key to maintaining and enhancing not only occupational health but also personal health and well-being among employees. In doing so, improved employee morale, enthusiastic leadership involvement, and encouragement often leads to significant gains in employee engagement and business partnership/productivity. The role of CMD demands business and health insights, rapid situational assessment, and response on a daily basis. The role must also include in-depth understanding of the business strategy and challenges so the design and delivery of world-class health and wellness programs can proactively target challenges and by doing so be a source of distinct competitive advantage.

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Acknowledgment

The authors wish to acknowledge the writing and editing contribution of Alyssa B. Schultz, PhD.

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