Primary Care and the Working Patient — Occupational Health Principles in Practice

What someone does for work, and where and when they do it, can have broad health impacts. This includes direct effects from physical job exposures and hazards. Many aspects of work also affect health in other ways such as through sleep and eating patterns, social connectedness, mental health stressors, and access to benefits like health insurance and paid sick leave.^1,2 These are called social determinants of health – non-medical factors that affect health outcomes.³

Why Does a Patient’s Job Matter?

Primary care providers (PCPs) see many work-related injuries and illnesses.^4,5 As such, they have important roles in diagnosing and managing work-related injuries and illnesses. Hazards at a patient’s job can affect their ability to work safely and productively. Work and work exposures can also impact a patient’s reproductive health, infectious disease risk, and chronic conditions such as cardiovascular disease and cancer—topics often first managed in primary care. In a 2018 survey, 35% of U.S. workers reported ever experiencing a work-related health problem.⁶ Consequently, it is important for PCPs to learn about their patient’s job, including the local industries at which they work (such as agriculture, construction, transportation) and the major work exposures they may experience.

PCPs also play a role in helping patients return to work after an illness or injury.⁷ Minimizing time away from work is associated with better outcomes for overall well-being.⁷

Opportunities to Enhance Occupational Awareness in Medical Education

Except for a few specialties (e.g., occupational medicine, preventive medicine), training on job-related health issues is often missing from medical education.⁸

Occupational medicine specialists are physicians that focus on the impact of work on health and manage work-related health conditions. This field is experiencing a growing shortage.⁹ Further, working adults are more likely to visit their PCP than an occupational medicine specialist for work-related conditions.⁹ Consequently, efforts to increase numbers of occupational medicine specialists, and equipping PCPs with tools to identify and manage common occupational conditions are necessary.

Take an Occupational History

A review of 2,050 physician charts in a large U.S. teaching hospital found that physicians, one-third of whom were residents, only included any mention of occupation in the chart for 28% of patients.¹⁰ Physicians were more likely to record information on other factors such as smoking and cancer history. PCPs can easily and quickly collect key elements of an occupational history. One method that is already being used by some healthcare organizations is to include simple occupation questions on screening intake forms at check-in. Once office staff or the patient completes the forms, the PCP can review this information and ask follow-up questions as needed.^11,12 Recording the information in the patient’s chart makes it easy to reference at future visits and update as needed. Some work-related information may already be collected for billing or other purposes. PCPs can get to know what work-related data their practice already collects.

The first work-related question to include is whether the patient has a paid job. From there, ask about their industry and occupation. Industry is the type of business in which a person works or what their employer does. Occupation is their job – what they do at work. Discuss and document open-ended information about both; each may be associated with risks or hazards that can affect health.¹³

Sample questions

Occupation

-What kind of work do you do? Or what is your job title? (e.g. registered nurse, janitor, cashier, auto mechanic, etc.)¹³

Industry

-What kind of business or industry do you work in? Or what does your employer make or do? (e.g. hospital, elementary school, clothing manufacturing, restaurant, etc.) ¹³

More detailed questions could include^11,14,15

Work status

-How long have you been working in your current position?

-Do you have more than one job?

Job-related exposures

-What sorts of things are you exposed to at work? For example, dust, fumes, chemicals, radiation, or loud noise at your workplace?

-How physically demanding is your work?

-How do your symptoms change when you are at work, or after you have been away from work for a while?

-Do you think your symptoms [or health problems] are related to your work?

-Does anyone else where you work have a similar health problem?

-Have you recently started working with any new materials or started doing any new activities at work?

Work schedule

-Tell me about your work schedule. (Note: long hours, shift work, multiple jobs, etc. can affect a patient’s ability to manage chronic illness and have other health effects)

Work stress and mental health

-How stressful is your work?

-How much control do you have at work over your schedule? Over your tasks?

A helpful memory aid that incorporates some of these questions is WHACS (What do you do? How do you do it? Are you concerned about any of your exposures on and off the job? Coworkers or others exposed? Satisfied with your job?).¹⁴ To round out an occupational health history, remember to ask about hobbies and unpaid work, too (e.g. home renovations).¹¹

What Next?

After a thorough history, physical examination, and initial tests, a PCP may suspect that a patient’s health problems or symptoms could be related to their job. What happens next? Depending on the problem:

• If specific hazardous exposures are suspected, a PCP could gather more information and review health effects of identified exposures.¹¹ Helpful resources include safety data sheets, which should be available on request from the employer, The NIOSH Pocket Guide to Chemical Hazards, and the Agency for Toxic Substances and Disease Registry (ATSDR).
• PCPs can recommend ways to reduce or eliminate exposure to hazards (e.g., substituting or switching out materials, workplace accommodations, personal protective equipment).
• If warranted, PCPs may refer patients to an occupational medicine specialist for more detailed assessment and management or other specialist(s) to incorporate a team-based approach to the patient’s care.
• PCPs can discuss safe return to work, which might involve returning to work at a reduced capacity, in a different role, and/or gradual resumption of normal work activity.⁷
• PCPs and occupational medicine specialists can educate patients about the NIOSH Health Hazard Evaluation Program where employers, workers, or their representative can request a free evaluation of potential workplace hazards.

Beyond the Exam Room

Collecting patient occupation information in a standardized way has far-reaching benefits. The NIOSH Occupational Data for Health framework supports collection of patient work information in a standardized way in electronic health records (EHRs).¹⁶ This information can help health systems, employers, and researchers better understand the relationships between work and health. It may also help inform medical surveillance guidelines for certain occupations or industries. Some states require certain occupational and environmental diseases to be reported, such as acute pesticide-related illnesses¹⁷ and work-related asthma.¹⁸ This reporting helps local public health authorities track these illnesses.¹⁶

Resources

There are several resources to support PCPs in identifying and managing occupational diseases.

Taking an Occupational History

A Case for Documenting Occupational History in the Medical Record (Medscape, 2010)

Occupational Medicine a Basic Guide (American College of Occupational and Environmental Medicine) (ACOEM)

National Institute for Occupational Safety and Health (NIOSH)

Workplace Safety and Health Topics

Do You Know How Occupational Data for Health Can Support Quality Care?

NIOSH Occupational Medicine Rotation

• A two-week virtual rotation with staff based at CDC/NIOSH in Cincinnati, OH. Current medical residents or fellows in a U.S.-based, American Council of Graduate Medical Education (ACGME)-accredited residency/fellowship program in any recognized specialty are eligible.

Agency for Toxic Substances and Disease Registry (ATSDR)

Resources for Health Professionals

Guidance for Return to Work

ACOEM Position Statement: The Personal Physician’s Role in Helping Patients With Medical Conditions Stay at Work or Return to Work

Referral to Occupational Medicine Specialists

Find a provider | ACOEM

Share Your Thoughts

As a patient, how often has a doctor or nurse asked you what you do for work? If you are a PCP, when do you think about work when evaluating a patient? How can we better teach our trainees about the intersections between work and health?

As mentioned above, methods or “controls” to reduce or eliminate worker exposure to hazards may be difficult for workers to implement themselves. In what ways can PCPs collaborate with the patient to bring the issue to employer’s attention?

Nadia Saif, MD, MPH, is an Epidemic Intelligence Service Officer in the NIOSH Division of Safety Research.

Christina Socias-Morales, DrPH, and Vidisha Parasram, DrPH, are Research Epidemiologists in the NIOSH Division of Safety Research.

Audrey Reichard, MPH, is Deputy Chief of the Surveillance and Field Investigations Branch in the NIOSH Division of Safety Research.

Sara Luckhaupt, MD, MPH, is the Associate Director for Science in the NIOSH Division of Field Studies and Engineering.

Marianne Cloeren, MD, MPH, is an Associate Professor in the University of Maryland School of Medicine Division of Occupational and Environmental Medicine.

Stella Hines, MD, MSPH, is Branch Chief of the Field Studies Branch in the NIOSH Respiratory Health Division.

Sophia Chiu, MD, MPH; Dallas Shi, MD, PhD; and Nicholas Somerville, MD, MPH; are Medical Officers in the NIOSH Division of Field Studies and Engineering.

References

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2. Silver SR, Li J, Quay B. Visual representation of work as a social determinant of health: Augmenting Silver et al., Employment status, unemployment duration, and health-related metrics among US adults of prime working age. Am J Ind Med. Aug 2022;65(8):697-698. doi:10.1002/ajim.23398
3. Public Health Professionals Gateway: Social Determinants of Health. Centers for Disease Control and Prevention. Updated May 15, 2024. Accessed August 30, 2024. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
4. Harber P, Mullin M, Merz B, Tarazi M. Frequency of occupational health concerns in general clinics. J Occup Environ Med. Nov 2001;43(11):939-45. doi:10.1097/00043764-200111000-00003
5. Won JU, Dembe AE. Services provided by family physicians for patients with occupational injuries and illnesses. Ann Fam Med. Mar-Apr 2006;4(2):138-47. doi:10.1370/afm.515
6. Free H, Groenewold MR, Luckhaupt SE. Lifetime Prevalence of Self-Reported Work-Related Health Problems Among U.S. Workers – United States, 2018. MMWR Morb Mortal Wkly Rep. Apr 3 2020;69(13):361-365. doi:10.15585/mmwr.mm6913a1
7. Jurisic M, Bean M, Harbaugh J, et al. The Personal Physician’s Role in Helping Patients With Medical Conditions Stay at Work or Return to Work. J Occup Environ Med. Jun 2017;59(6):e125-e131. doi:10.1097/JOM.0000000000001055
8. Eu E, Soo MPJ, Gan WH. A short review of undergraduate occupational medicine training. Occup Med (Lond). Oct 27 2020;70(7):485-489. doi:10.1093/occmed/kqaa131
9. Green-McKenzie J, Khan A, Redlich CA, Margarin AR, McKinney ZJ. The Future of Occupational and Environmental Medicine. J Occup Environ Med. Dec 1 2022;64(12):e857-e863. doi:10.1097/JOM.0000000000002676
10. Politi BJ, Arena VC, Schwerha J, Sussman N. Occupational medical history taking: how are today’s physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major US teaching center. J Occup Environ Med. Jun 2004;46(6):550-5. doi:10.1097/01.jom.0000128153.79025.e4
11. Taiwo OA, Mobo BH, Jr., Cantley L. Recognizing occupational illnesses and injuries. Am Fam Physician. Jul 15 2010;82(2):169-74.
12. Weissman DN, Radonovich LJ. Importance of and Approach to Taking a History of Exposures to Occupational Respiratory Hazards. Semin Respir Crit Care Med. Jun 2023;44(3):396-404. doi:10.1055/s-0043-1766120
13. Collecting and Using Industry and Occupation Data. National Institute for Occupational Safety and Health. Updated June 29, 2022. Accessed June 24, 2024. https://www.cdc.gov/niosh/topics/coding/collect.html
14. Papali A, Hines SE. Evaluation of the patient with an exposure-related disease: the occupational and environmental history. Curr Opin Pulm Med. Mar 2015;21(2):155-62. doi:10.1097/MCP.0000000000000138
15. Sara E. Luckhaupt GMC. A Case for Documenting Occupational History in the Medical Record. MedscapeCME Public Health & Prevention. 2010. Accessed June 24, 2024. https://www.medscape.org/viewarticle/715473
16. L Brewer BW, G Luensman. Do You Know How Occupational Data for Health Can Support Quality Care? NIOSH. Accessed June 18, 2024. https://doi.org/10.26616/NIOSHPUB2022119
17. Introduction to Pesticide Incidents. Environmental Protection Agency (EPA). https://www.epa.gov/pesticide-incidents/introduction-pesticide-incidents
18. Work-Related Asthma Reporting Guidelines. National Institute for Occupational Safety and Health (NIOSH). Updated January 19, 2024. https://www.cdc.gov/niosh/surveillance/respiratorydisease/work-related-asthma-reporting-guidelines.html