Occupational Medicine for Medical Students at the Faculty of Health/University of Panama

Introduction This module aims to provide students with understanding of and tools to describe and analyze how workplace risk factors determines and interacts with the worker´s health: The course shall provide insights of how to undertake clinical examens to identify work related health conditions of all types of patients and propose adequate prevention intervention advices. Further the students will understand how the primary-, secundary and tertiary prevention types interact in all patients and populations. More specifically that all diagnosis, etiology, treatment, prevention, prognosis, notification and compensation are obligatory issues for occupational- as all other medical patients. Occupational Medicine for Medical Students

Introduction

Seafarer on board a ship.

Miraflores locks in the Panama Canal

Pineapple Harvest in the Philippines

Sugar Cane Harvest

The incentive to start the Wikibook was based on the increasing problem on chronic renal diseases of unknown origin among the poorest farm workers in Central America, Sri Lanka and other tropical countries - as described in this Wiki The Mesoamerican nephropathy. The victims of this deadly disease are most often among the poorest agricultural workers and we have to ask why hash´t this disease never been diagnosed as an occupational disease. Part of the answer may relate to the fact that the tropical occupational medical problems are mostly absent in the occupational medical textbooks written by authors from outside the tropical areas. There is a strong need for the development of occupational medicine in the developing tropical countries. The intention is to strengthen the development of occupational medicine as a clinical speciality and the development of an occupational health peventive culture and practice globally. No to forget that occupational accidents constitute an important part of work related health complaints, so the definition and the prevention of the work related accidents will be included here as well. All health professionals are invited to participate with linguistic corrections and by adding new texts and chapters. When the book is more developed we hope it will be used as one of the basic books for teaching occupational health in tin the tropical countries. The book is primarily in English, later in Spanish and other languages. Welcome to use and to particpate in the development of this Wikibook. Please note, that many of the headlines can be opened with links to Wikipages not to repeat what already has been well described.

Asclepius

Bernado Ramazzini

Preventive healthcare

Occupational medicine is a medical speciality that aims for the prevention among workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health need to be studied so epidemiological research is an important part of the speciality; placing and maintenance of a worker in an occupational environment adapted to his physiological and psychological equipment and the promotion and maintenance of physical, mental and social well-being of workers.

Social determinants of health (Social Medicine)

The association between socioeconomic status and health has been known for centuries . The socioeconomic derterminants of health is a sine qua non in all medical specialities includning occupational medical research and clinical practice. Socioeconomic status is related to mainly three indicators: education, income and occupational status. Powerty is a strong indicator for mental and physical occupational diseases Today the field of social medicine is most commonly addressed by public health efforts to understand what are known as social determinants of health. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Hippocrates sought to show a connection between the climate of the area and the diseases that plagued that area, still he also must have known the impact of the socioeconomic indicators for disease

Critical thinking

Critical thinking and asking questions is significant in academics, research and especially important in occupational medicine. One basic question for the physicians is to ask the patient about his/her job and to pursue the causalities of the disease in order to propose prevention in the branch and for the patient. Critical thinking is closely related to Evidence Based Medicine, as described below

Evidence-Based Medicine

Evidence based medical practice is an approach to clinical decision making that has gained considerable interest and influence during the decades. The phrase 'evidence based medicine' originated in the 1980s as a way of describing the problem based learning approach

Medical diagnosis

Medical diagnostics is "sine qua non" in occupational medical practice with patients and epidemiological research. The occupational clinical diagnosis is closely related to the establishment of the causality, as the diagnostic and compensation of an occupational disease involve the diagnosis and the probability of the etiology.

Medical causality

Medical causality or etiology is "sine qua non" in medical practice with patients and research for adequate treatment and prevention with roots back to Aristotle Wikipedia Aristotle. Especially for occupational medicine, the development of causality is closely related to the diagnostic process of the single patients and epidemiological research. The importance of the work as possible contribution factor to many diseases was stated by Doctor B.Ramazinni from Italy some 300 years agoArticle in Wikipedia

Medical prognosis

Occupational medical prognosis and advice to the patient depend on the diagnosis, the seriousness of the disease and the specific working conditions. The occupational medical advice might include that the patient needs to change job or leave the labour market.

Code of Medical Ethics

Hippocrates

The international Code of Medical Ethics forms the basic content of the specific demands of ethics in all the medical specialities. The Spanish version is more elaborated than the English Spanish version. The ethics for occupational physicians are normally seen from two main viewpoints: 1) the legal standing and ethics in job execution; 2) ethics in research on occupational medicine. Among lots of guidelines we choose for a start the International Code of Ethics for Occupational Health Professionals from the ICOH code of ethics and the translation into Spanish ICOH Ethics code in Spanish.

Occupational diseases

The underreporting of occupational accidents and occupational diseases, globally is well recognised. However, the degree of underreporting is especially high in Latinamerca .For 2010 in Panama (1,5 million economic active) 66 occupational diseases . For comparison in Denmark with 2,6 million economic actives there were reported about 20000 occupational diseases. Of course any comparison depends on a lot of different conditions on the labor market, of the definition of the inclusion criteria and the degree of underreporting. These issues will be debated in the text.

Occupational accidents

The underreporting of occupational accidents and occupational diseases, globally is well recognised. However, the degree of underreporting is especially high in Latinamerca .For 2010 in Panama (1,5 million economic active) there were reported 10,311 occupational accidents, 66 occupational diseases and 135 fatal accidents . For comparison in Denmark with 2,6 million economic actives there were reported about 20000 occupational diseases, 44000 occupational accidents (at least 1 day off from work) and only 39 fatal accidents. It is supposed that the underreporting for non-fatal accidents is about 50%. From 10 different information sources the estimate was 8.3 per 100,000 in 2005 100,000 employed

Occupational medicine in general practice

General practice and occupational medicine share close similarities in their focus on disease prevention and health promotion. The workforce constitutes a significant part of the population and thus the patient load of a typical primary healthcare practice. Moreover, with an ageing population and rising retirement age, we can expect that there will be an increasing number of health issues to be addressed among older working people. Both occupational and non-occupational factors are important in determining an individual's health. Thus, family physicians need to adequately understand occupational medicine and vice versa .Most occupational health care will continue to be provided by family physicians, who may also be the physicians closest to the workers and their families. There are many opportunities for family physicians to develop their skills in occupational health care and to incorporate occupational medicine into their practices

Occupational psychiatry

Organisational and occupational psychiatry (OOP) is the subspecialty of psychiatry that focuses on work, its importance in the lives of individuals and work organizations. The psychiatrists do many important occupational health functions. For example they help the patients to stay in the job or to get another change position without the mental hazards they have been exposed to. As the psychiatry include much occupational medicine, a specific chapter will be written about the occupational psychiatry. However there is a gap of knowledge on how much mental disease and symptoms are related to job hazards not only in Panamá but globally. Therefore it is found relevant to do a prevalence study of the proportion of mental disease associated with job hazards. The study is similar to a study planned for general practice. The objective is to answer the questions: How many per cents of the mental health disease can be related to hazards in the work-place? Why should the study be done a psychiatry hospital and not in general practice? The answer is that the patients in the psychiatric clinics are selected via the General Practice. So the main part of the patients have an established psychiatric diagnosis. The questionnaire page 2 is different than that for general practice. On page two the psychiatrist will mark the general area of the ICD-10 diagnosis and not the International Classification of Primary Care (ICPC) that is used for general practice. This has the methodical advance that the diagnosis is on a specialist level and less patients is needed to make conclusions about the percentage of work-related psychiatric diseases. Psychiatry questionnaire % related to work

Occupational dermatology

Dermatologic complaints are among the most common occupational illnesses. Many occupational exposures can cause skin disease. The most frequent occupational skin disease is contact dermatitis. This may be either irritant or allergic contact dermatitis but often is a combination of both. Irritations may occur from chemical factors including caustics, solvents, detergents, and even plain water. Physical factors that cause irritation include friction, repeated trauma, heat, and low humidity. Contact allergy may be caused by several thousand chemicals and substances, but relatively few agents are common causes of allergic contact dermatitis. Some of the more important include metals (nickel, cobalt, chrome), preservatives, rubber additives, and plastic components (epoxy resins, acrylates). Contact urticaria is an immediate hypersensitivity reaction distinct from allergic contact dermatitis. Latex allergy is the most well-known cause of immunologic contact urticaria, but many other substances, usually protein-based, can also cause contact urticaria. A variety of other skin conditions can also be occupationally related. Skin cancer caused by ultraviolet light (sunlight) exposure or certain chemicals can be attributed in some cases to occupational exposure. Chloracne, a specific acneiform eruption caused by exposure to various halogenated hydrocarbons, is a sensitive indicator of systemic exposure to these agents. Various cutaneous infections are seen more commonly in some occupations, such as warts in meat cutters or erysipelothrix in fishermen. Cutaneous hypopigmentation (chemical leukoderma) can be seen in certain workers who are exposed to depigmenting agents such as phenolic germicides. Systemic sclerosis has been occasionally seen in association with certain job exposures. In evaluating a patient with a possible occupational dermatosis, accurate diagnosis is essential. Certain diagnostic tests, especially the patch test, are important adjuncts to the clinical evaluation. Consideration of nonoccupational components of the disease (confounders) is necessary to arrive at a proper assessment of causation. Fowler Jr JF. Occupational dermatology. Current Problems in Dermatology. 1998 Nov;10(6):211–44.

The needs for more public-,scientific- and political interest

Occupational health remains neglected in developing countries because of competing social, economic, and political challenges. Occupational health research in developing countries should recognize the social and political context of work relations, especially the fact that the majority of developing countries lack the political mechanisms to translate scientific findings into effective policies.

Impact of unions and safety representatives

Research on safety reps’ effectiveness and impact on occupational health lend support to the notion that trade unions, joint arrangements, and trade union representation on occupational health and safety are associated with higher levels of compliance, lower workplace injury rates and ill-health problems, and better overall health and safety performance Unions importance for occupational health & safety (Shannon et al., 1997; Milgate et al., 2002; Walters 2006).

Action research in the workplace

Bernardino Ramazzini (1633–1714) published his most famous book 1713, De Morbis Artificum Diatriba (Diseases of workers) Ramazzini . The book is a descriptive account of working conditions in more than fifty occupations and of the diseases of workers in these occupations. Ramazzini's observations were accurate and precise, although he provided no numerical information and made statements implying rather than expressing levels of risk, so readers could not determine, for example, whether pottery was a safer occupation than knife grinding. His accounts remain a good model for occupational health. We want to continue in his footsteps by describing the working conditions in the diferent occupations and the diseases of the workers but in a modernized form, action research. The descriptions will be based on the workers own descriptions and proposals for prevention and the existing scientific evidence about the exposure hazards and the health risks. The objective is to prepare the health professionals with knowledge about the workers´daily conditions so they are well prepared to establish the correct diagnosis, identify the causal factors and so to give the best treatment and guide for prevention. And possibly notify the disease or symptoms as work-related where relevant. Further it is the aim to increase the political interest for prevention of the specific problems.

Descriptions of the health and risks in the jobs

• Los trabajadores de la construcción
• Los canillitas
• E-nomads Workers without any fixed office that use all the avialable technological resources, always staying available are the 21st century electronic working nomads.

“Where are the sections on industrial/occupational hygiene?”

There are no separate sections on industrial/occupational hygiene and why not ?” it is there - but with other words. The concepts in occupational medicine have changed over time and the concept occupational hygiene has been in some countries replaced by other words like occupational health risk assessment. Please also see the Wikibook American_Industrial_Hygiene_Association The same question can be added about Toxicology, - see more by opening the chapter.

Community intervention programs

EBM

Health interventions applied on a community-wide basis have come into increasing use in public health and epidemiologic research over the past decades. The emphasis on interventions focusing on communities has created distinct methodological challenges for researchers. Effective program evaluation is a systematic way to improve and account for public health actions. Evaluation involves procedures that are useful, feasible, ethical, and accurate It is important to develop a tool to measure success and to include these results in the promotion campaign. Even if the program is part of the global campain, it is essetial to establish goals and measure the progress against your goals. By reviewing the program’s successes and failures you can see how it has been the most effective. In conclusion there is a need to add research programs to the interventions. This could be an attractive research area for public health students in Panama and students from outside!

Post-grade training courses

The intention is to offer short theoretical and practical courses, that are of relevance to improve the quality of the daily practice in not alone occupational medicine but all areas of medical and health practices and research

Dr. John Snow Cholera Map

1. Epidemiology

Research is an indispensable part of occupational medicine and the epidemiology is traditionally viewed as the main research tool for occupational medical researchers, practitioners and administrators. Though many other disciplines are important to occupational medicine the epidemiology is often described as the ‘basic science of public health and occupational medicine. Unfortunately the university teaching in epidemiology rarely give the students sufficient interest and understanding of the basic principles of epidemiology . Therefore we want to amend the gab of skills and knowledge by offering an integrated course in Epidemiology. The course forms the scientific base for the other three courses (see below) This course will include epidemiology as an integrated part of EBM, OM and basic research. [[File:EBMfr.jpg|200px|th

2. Evidence Based Medicine

The participants will learn to pose relevant questions related to medical diagnosis, treatment, prevention and research. Further to search the relevant literature, read and get the information and be able to communicate the message and the answer to the question effectively and systematically. Some useful existing reviews and guidelines for occupational medicine diagnosis will be presented and explained how they were developed. https://en.wikipedia.org/wiki/Evidence-based_medicine

3. Occupational Medicine

We are planning to offer short OM courses for students, nurses, physicians at the hospitals, general practice and other health professionals. Later we pretend to offer more advanced courses when the course materials are sufficiently developed. The courses will be structured like the content of this Handbook. The intention is that the participants will add new knowledge to the Handbook and get a valuable learning at the same time. The course content reflect the content of the Handbook. The aim of the course is to improve the diagnostics, treatment and prevention of occupational diseases in Panamá by application of the Evidence Based Medicine. After the course the participants will be better to establish the diagnosis and give attention about the notification as occupational diseases. Also be better to try to discover any relevant relation between the work hazards (psychological, physical, chemical, ergonomic etc) and the symptoms. This in order to give the best advice on how to solve the problems for the patient and how to prevent the same could happen for others. The participant will learn to edit and to add text and new chapters to the Wikibook. The homework could be to write and add a chapter to this book, for example 1) diagnostic guidelines for occupational asthma or 2) description of the work processes and health risk factors for urban bus drivers.

4. Basic research course for health professionals

The programme for a basis course in health research

We are planning to offer a basic research training course for health professionals in the clinics and in the health administrations. The participants should have access to patients (handout the questionnaires) or access to administrative health data. The participants will stepwise learn how to plan and perform an epidemiological prevalence study based on a given questionnaire. See the questionnaires for general practice, dermatology and psychiatry. Training in the relevant computer programs like Epidata is included. The aim of the training is that the participants will add knowledge to the Handbook and get a relevant learning at the same time. Patient records in general practice (and health registers in the public administrations) are unique resources that can provide evidence to help to improve their understanding of research, improve patient diagnostics (attention to occupational medicine), patient treatment and prevention. We hope the course will be a valuable for general practitioners, administrative health professionals, medical and nurse students and other students so that many of them will enter in to active research activity. After the course the participants will be able to perform their own research, do literature searches and publish articles.

General Practice

Encuesta GP

Dermatology

Encuesta dermatologia

Psychiatry

Encuesta psychiatria

Research plan for each speciality

• Phase 1 Prevalence study of suspected occupational diseases (in general practice, dermatology, psychatry and rheumatology) 5 main group of industries with the standard questionnaire
• Phase 2 Prevalence study of suspected occupational diseases in the specific job categories, use of Standard Industrial classification
• Phase 3 Intervention study: Instruction is given to the physians, the list of ILO and the country specific recognised occupational diseases and compared without instruction

The Panamenian Journal of Public, Occupational and Environmental Health

La Revista de la Salud Publica, Ocupacional y Ambiental de Panama The course participants are invited to publish their comments and scientific work in this journal. The academic requirements are less than for international indexed journals, but still contribute with important new knowledge for the development of the occupational medicine in Panama. The articles can later be published in revised form in indexed international scientific journals. Articles with relevant new original knowledge will be added to the Handbook. So there is a dynamic relation between the journal, the research courses and the Wikibook. Revista de Salud Publica, Ambiental y Ocupacional de Panama

Research protocols

Rules for research in the CSS hospitals in Panama

The documents needed for a scientific study in the CSS hospitals are the following:

1. Formulario para someter protocolos de investigación
2. Declaración del Investigador.
3. Guia para la redacción los protocolos de investigación - OPS
4. Guia para redactar consetimiento informado
5. Registro de Responsabilidades

1. Estimate of the size of the chronic renal disease of undetermined origin (CKDu) problem in Panama

La insuficiencia renal crónica de causas no tradicionales

2 Clinical Case (CKDu)

Occupational Clinica Case Study protocol

3 Ethiological study on risk factors for chronic renal disease of undetermined origine

Etiological case-control study protocol

References

.