The general practitioner in industrial medicine

Most industrial injuries are treated by physicians who have a general practice in addition to their industrial work. Because of the increasing number and seriousness of industrial injuries, better preparation for treatment is required in the patient's interest and for reasonable economy. The trend toward centralization of industrial medical facilities, increasing before and during World War II, has been somewhat reversed; the general practitioner now has an opportunity to take a useful place in the care of injured employees.A physician dealing with industrial cases must be prepared to give immediate emergency treatment, to comply with the procedures of insurance carriers, and to refer cases which he is not skilled or equipped to handle. As a personal physician having the confidence of the patient he can secure greater cooperation from all parties concerned in industrial disability and can sometimes promote a more rapid recovery.     

FACTS AND FALLACIES ON INDUSTRIAL POISONING

Misdiagnosis of diseases as due to industrial poisoning leads to much misunderstanding, higher taxes and insurance rates and “compensation neuroses.” It is important to know the concentration of the suspected poison and its specific effects in order to logically indict it as the cause of illness. Examples discussed to illustrate some of the pitfalls of diagnosis in industrial medicine are methylbromide, carbon monoxide, ozone, oxides of nitrogen and of sulfur, hydrogen sulfide, benzene analogs, boron and fluorides.     

Workmen's compensation; emphasis on rehabilitation

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled. An effective workmen's compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned. It is the physician's responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.     

WORKMEN'S COMPENSATION—Emphasis on Rehabilitation

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled.An effective workmen''s compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned.It is the physician''s responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.     

On the challenges and mechanisms of embodied decisions

Neurophysiological studies of decision-making have focused primarily on elucidating the mechanisms of classic economic decisions, for which the relevant variables are the values of expected outcomes and action is simply the means of reporting the selected choice. By contrast, here we focus on the particular challenges of embodied decision-making faced by animals interacting with their environment in real time. In such scenarios, the choices themselves as well as their relative costs and benefits are defined by the momentary geometry of the immediate environment and change continuously during ongoing activity. To deal with the demands of embodied activity, animals require an architecture in which the sensorimotor specification of potential actions, their valuation, selection and even execution can all take place in parallel. Here, we review behavioural and neurophysiological data supporting a proposed brain architecture for dealing with such scenarios, which we argue set the evolutionary foundation for the organization of the mammalian brain.     

Legal issues in accidents caused by sleepiness

The impact of shift-work on sleep, performance and general health appears to be substantial. The most immediate consequence of night shiftwork is sleep loss. The aim of the present paper is to describe legal cases involving accidents attributed to sleepiness or fatigue, mainly as a consequence of shift-work or prolonged work hours, in the UK, USA and Australia. The paper will describe how legal systems are dealing with such incidents and how this may change in the future. Accidents related to sleepiness may result in criminal prosecution, for example charges of culpable driving. For acts performed while a person is sleeping (e.g., motor vehicle accidents), the legal question of voluntariness may be raised. The issue of employers' liability in such cases is contentious. Special liability regimes are in place to cover employers' liability. Employers may be deemed liable for injuries of third parties caused by wrongful acts of employees committed in the course of their employment. In the future, it is likely that employers will need to take greater precautions to reduce sleepiness and fatigue in the workplace, especially where the risk to public and environmental safety, health and productivity are significant.     

HEART DISEASE UNDER WORKMEN'S COMPENSATION

In expert testimony before the Industrial Accident Commission, all physicians are taken as equally competent. The value of their testimony depends upon the validity of their data and the reasons for the conclusions drawn. In case of conflicting opinion, the referees, who are laymen, must decide on the basis of the testimony. Therefore physicians preparing reports must see that data are complete, that all routine investigative procedures are not only applied but reported, and that the reasons for claiming connection of injury with employment are fully stated. Moreover, other recognized causes of the patient''s condition should be considered and ruled out for reasons given.The increasing number of claims for workmen''s compensation in heart disease, and the increasing tendency of insurers to settle rather than contest claims, may actually be harmful to the welfare of persons with heart disease, for it deters employers from hiring them and thus risking higher insurance costs. Physicians concerned with compensation claims must develop more widely acceptable standards that properly separate the inherent risk of heart disease from that incurred through employment for which the employer may reasonably be considered liable.     

Ecohydrology of saline grasslands: Consequences for their restoration

Abstract. By the approval of the European Bird Directive (79/409/EEC) in 1979 and the Habitat Directive (92/43/EEC) in 1992, nature protection has become an important part of European law with direct consequences for land use, industrial development and agriculture. If a member state reclaims an area that is protected by these directives, it has to take compensational measures. When such an area includes saline grasslands that require very specific abiotic conditions, a place with similar conditions must be available to re‐establish those grasslands at another location in a sustainable way. This will limit the number and extent of possible sites for compensation. In the conflict between economy and ecology in the Schelde polders, Flanders has chosen to expand the port of Antwerp in the polders at the left Schelde bank and destroy a protected saline grassland site. As a consequence, it has to compensate for this loss. Therefore, we made a detailed study of the hydrology, geology and soil conditions of the endangered saline grassland site. The same was done in four possible compensation sites, all situated in nearby polders. We found that the presence of upwelling groundwater flowing through a saline peat layer is necessary for the occurrence of saline grasslands. Only in one of the four possible compensation sites, called Muggenhoek, we found such conditions. So, we indicate this place as a possible site for the re‐creation of saline grasslands and give some recommendations for their development.     

Why not private health insurance? 2. Actuarial principles meet provider dreams

What do insurers and employers feel about proposals to expand Canadian health care financing through private insurance, in either a parallel stream or a supplementary tier? The authors conducted 10 semistructured, open-ended interviews in the autumn and early winter of 1996 with representatives of the insurance industry and benefits managers working with large employers; respondents were identified using a snowball sampling technique. The respondents felt that proposals for parallel private plans within a competitive market are incompatible with insurance principles, as long as a well-functioning and relatively comprehensive public system continues to exist; the maintenance of a strong public system was both socially and economically desirable. With the exception of serving the niche market for the private management of return-to-work strategies, respondents showed little interest in providing parallel coverage. They were receptive to a larger role for supplementary insurance but cautioned that they are not willing to cover all delisted services. As business executives they stated that they are willing to insure only services and clients that will be profitable.     

Survey on Ethical Conduct Thresholds in Cardiologal Medical Practice in Argentina

The purpose of this study was to analyze the attitude of a group of cardiologists on the ethical conducts they would accept or adopt when encountered with different hypothetical situations of medical practice. Between August and September of 2011, 700 Argentine cardiologists were surveyed in situations which posed ethical dilemmas in the patient‐physician relationship, among colleagues or involving financial agreements with employers or the pharmaceutical industry. Ethical conflicts were evidenced in a series of inappropriate conducts such as differential fees, trips and meals sponsored by laboratories, splitting fees, overbilling, self‐referral, charging for patient referral, financial compensation for ordering medical procedures, and various situations derived from the relationship with employers. In general, financial compensation from the pharmaceutical industry was more accepted than the conflictive situations which directly involved patients, colleagues or employers. The rejection of these conducts, the physicians' deontological education and the improvement of financial and organizational conditions in medical practice will help to encourage better medical professionalism and avoid unseemly behaviors.     

Occupational cancer: experience in Ontario.

This paper reviews the experience of the Workmen''s Compensation Board of Ontario in identifying cases of cancer that could be attributed to occupational hazards. Worker''s claims for compensation are allowed if there is reasonable medical evidence that their cancer was caused by exposure to risk factors associated with their occupation. Details of the types of cancer associated with specific carcinogens or fields of employment are discussed. About 50% of the cases were related to exposure in particular industrial operations that functioned for relatively brief periods. The number of deaths from cancer identified as being caused by occupational factors is compared with the total for cancer from all causes in Ontario during the period 1971 through 1975. Although all workers eligible for compensation may not have been identified, the data suggest that less than 1% of cancer is presently caused by occupational factors.     

Cumulative Injury

A few states, notably California, are experiencing large increases in the number and cost of disability settlements under workers'' compensation. Claims of cumulative injury for coronary heart disease, hypertension, stroke, cancer and neuropsychiatric problems have all been interpreted as compensable under workers'' compensation, even when these conditions are clearly related to the aging process. Legal precedents for such claims are building rapidly throughout the country. The resultant costs may lead to the demise of the workers'' compensation system. The situation in California is discussed in detail including the legal aspects, cumulative injury claims by type of disease and age of claimants, legal costs to the individual and the employer, and the economic outlook for the workers'' compensation insurance system.     

Disclosure of personal medical information: differences among parents and affected adults for genetic and nongenetic conditions

Protecting the confidentiality of medical information has been an issue of great interest in the fields of bioethics, public policy, and law. Few empirical studies have addressed patient experiences and attitudes toward disclosure of private medical information in multiple contexts such as health insurance, employment, and the family. Furthermore, it is unclear whether differences exist in experiences and attitudes about privacy between those living with a serious medical condition versus those who have a child with a medical condition. The study sought to determine whether attitudes and experiences related to medical privacy and confidentiality differ between affected adults and parents of affected children. Interviews were conducted with 296 adults and parents of children with sickle cell disease (SCD), cystic fibrosis (CF), or diabetes mellitus (DM). This cross-sectional study collected data regarding their experiences, attitudes, and beliefs concerning medical privacy and confidentiality. Multinomial logistic regression analysis was conducted on quantitative data. Qualitative analysis was conducted on data from open-ended response items. Parents disclose their child's diagnosis to others more often than affected adults disclose their own disease status. Parents are less likely than affected adults to regret their disclosure, to hope others do not find out, to have been pressured to share information, and to be asked about their disease by employers. Affected adults express greater concern about disclosure, a greater prevalence and greater fear of discrimination, and experience greater pressure from family members to disclose. Clinicians and researchers working with these populations should consider these differences in privacy and disclosure. Further study is necessary to examine the implications of these differences in attitudes and experiences concerning insurance, employment, and social interactions among persons with these conditions.     

Expert witness reform

The legal system depends on the medical expert for evidence. Doctors readily complain about frivolous cases that go to trial, yet a lawyer cannot bring a frivolous claim to trial without a physician expert witness stating that the claim is not frivolous. An insurance company cannot raise premiums without medical expert witnesses servicing the increasing litigation against the insured. Physicians must look to themselves as a major contributor to rising malpractice insurance costs. For without the physician expert witness, no medical malpractice lawsuit can take place. It is the expert physician, not the attorneys or insurance companies, who defines "meritless" and "frivolous" and who ultimately controls the courts' medical malpractice caseload.     

Attitudes of California Dermatologists Toward Worker's Compensation: Results of a Survey

A survey-questionnaire on Worker''s Compensation sent to 492 California dermatologists produced 268 replies, a recovery rate of 54 percent, representing approximately 10 percent of the practicing dermatologists in the United States. A total of 75 percent replied they treat Worker''s Compensation patients; most of the 25 percent who replied they do not gave strong reasons for refusing to assume the care of these patients. The answers to the questionnaire given by the 201 California dermatologists who treat Worker''s Compensation patients are tabulated and discussed. Although there exists considerable misunderstanding among physicians, insurance companies and employers on many aspects of Worker''s Compensation, the situation is not without hope for improvement. Better knowledge of work procedures, more availability of precise information on the ingredients of work contactants and cooperation among the interested parties should improve the quality of care for these patients in the future.     

西北某医院老年性白内障不同付费方式患者费用构成分析

目的:通过对比分析,总结西北某医院老年性白内障自费、医保、新农合三类付费方式患者医疗费用差异及其原因。方法:提取西北地区某医院2010-2012年老年性白内障患者的基本病例信息及住院费用清单,利用EXCEL2007软件和SPSS18.0软件对数据进行统计分析。结果:本院老年性白内障患者人均住院总费用最高为自费患者,其次是医保患者,最低为新农合患者。其中,药品费用差异悬殊是导致三类患者住院总费用差异的最主要原因。结论:不同付费方式对医疗收费行为产生不同影响,医保和新农合政策的制定应兼顾效率与公平。     

The ‘other’ looks back: racial distancing and racial alignment in migrant domestic workers' stereotypes about white and Chinese employers

While the racial and ethnic stereotyping practised by the employers of migrant domestic workers has received significant scholarly attention, these workers' racial essentializations of their employers have been largely ignored. Drawing upon interviews with Filipino migrant domestic workers in Singapore and Hong Kong, I present findings concerning the racial stereotypes these workers hold about white and Chinese employers. This stereotyping involves both racial distancing from local Chinese employers and racial alignment with expatriate white employers. This two-track racial project is a defensive tactic that allows Filipino workers to redefine themselves as occupying a higher position in the global racial order (as they see it) on cultural grounds. However, it also makes them complicit in naturalizing legacy stereotypes that valorize whites as morally and culturally superior. In addition, it encourages them to privilege the West as an idealized destination where they fantasize they will enjoy comfortable working conditions from local white employers.     

Zygosity diagnosis in young twins by questionnaire for twins' mothers and twins' self-reports.

The present study deals with the determination of zygosity in twins of childhood age by simple questionnaire. The subjects were 224 twin pairs and their mothers, consisting of 159 monozygotic and 65 same-sex dizygotic pairs, identified by genetic markers including DNA samples. Mothers of twins responded to 19 questionnaire items dealing with twin similarity in 16 items about physical features and 3 items about the degree of similarity and frequency of being mistaken (confusion of identity) when twins were about 1 year of age. The twins themselves responded to three questionnaire items dealing with only confusion of identity items. The results of stepwise logistic regression analysis were as follows: the total accuracy of the mothers' questionnaire was 91.5% when using only the items dealing with confusion of identity. This accuracy was slightly lower than that obtained by twins' self-reports dealing with nearly the same question items of confusion of identity, answered by both twins separately with 93.3% accuracy. The total accuracy of mothers' questionnaire responses rose to 95.1% when we used all 19 items. In addition to "the frequency of being mistaken", two physical features, namely "shape of fingers" and "shape of eyebrow", were very informative. In conclusion, twin zygosity can be estimated by the use of the mothers' simple questionnaire with sufficient accuracy even in very young twins about 1 year of age.     

Addiction,Voluntary Choice,and Informed Consent: A Reply to Uusitalo and Broers

In an earlier article in this journal I argued that the question of whether heroin addicts can give voluntary consent to take part in research which involves giving them a choice of free heroin does not – in contrast with a common assumption in the bioethics literature – depend exclusively on whether or not they possess the capacity to resist their desire for heroin. In some cases, circumstances and beliefs might undermine the voluntariness of the choices a person makes even if they do possess a capacity for self‐control. Based on what I took to be a plausible definition of voluntariness, I argued that the circumstances and beliefs typical of many vulnerable heroin addicts are such that we have good reasons to suspect they cannot give voluntary consent to take part in such research, even assuming their desire for heroin is not irresistible. In a recent article in this journal, Uusitalo and Broers object to this on the grounds that I misdescribe heroin addicts' options set, that the definition of voluntariness on which I rely is unrealistic and too demanding, and, more generally, that my view of heroin addiction is flawed. I think their arguments derive from a misunderstanding of the view I expressed in my article. In what follows I hope therefore to clarify my position.     

Misunderstanding in the classification of diabetes mellitus. What's in a name?

To assess whether physicians, residents, medical students, hospital diagnosis coders, and patients properly use the designations insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) that were established by criteria of the National Diabetes Data Group, we reviewed clinic and hospital records and administered questionnaires. Although essentially all cases of true IDDM were identified as such and most cases of NIDDM not requiring insulin therapy were correctly identified by all groups, patients with NIDDM on insulin therapy were misidentified as having IDDM by 38% of residents in internal medicine clinics and 68% of primary care and surgical subspecialty residents. On a survey, of 22 patients with NIDDM on insulin therapy, 17 (77%) considered themselves to have IDDM. Thus, patients who have NIDDM by the established criteria who are on insulin therapy are commonly mislabeled as having IDDM. We present an approach for dealing with this problem by adapting nomenclature focusing on insulin deficiency and resistance. It would probably also be helpful to separately identify the subset of patients with "insulin-deficient diabetes" who are ketosis-prone. It is important to use immunologic profiling (islet cell antibody testing) and insulin sensitivity or deficiency testing (C-peptide levels).