Wide social inequalities in health are found in all European countries, but they are rarely put down to work. The social invisibility of the interplay between health and work is exacerbated by the lack of contact between works doctors and family doctors. How can these two key players for the health of workers interact more effectively? Two Belgian doctors give their thoughts and some pointers to improvement.
Interview with Dominique Roynet and Florence Laigle
General and occupational medicine are often portrayed as two worlds indifferent to one another despite working to the same end of promoting people’s health. Why is that?
Dominique Roynet — Much of the reason there is so little communication between GPs and occupational doctors is because workers don’t see the works doctor as standing up for them so much as siding with the boss. Our patients act as a sort of filter between the two medical professionals. Very often they confuse the occupational doctor with the examining doctor sent by their employer. There is a huge lack of awareness of the world of work among GPs. GP training is still focused on medical treatment in the strict sense – the social, occupational, psychological and legal aspects are still overlooked today. As far as I am aware, occupational medicine is not taught on medical degree courses for general practitioners.
Florence Laigle — There is a huge knowledge gap among workers about what occupational doctors do, and it is not much better among family doctors. There are so many misconceptions going around about us, like supposedly not being independent of employers. Occupational doctors are not forthcoming enough about their job and the profession suffers from a poor image.
What circumstances in your daily practice might bring you into contact with your opposite number?
DR — Very broadly, I can say that I only come into contact with occupational medicine in two cases: where a pregnant worker has to be moved away from a dangerous work environment, or where a job adaptation is needed so my patient can keep on working. Hardly ever do I have a patient asking me to contact his works doctor. I have had it only once in 31 years of practice, and that was a graduate who was well-versed in all the ins and outs of the procedure.
FL — When I ask for information from a family doctor it’s usually to do with redeployment in the company, and obviously with the worker’s consent. It’s a purely practical approach, i.e., I need to collect objective information on the worker’s health from the practitioner who best knows his health, which is either his family doctor or a specialist. I always make the request in writing, and always emphasising that there are two scales to balance – health on one side, the job on the other. The company I provide services to (in the waste management sector – ed.) has a very high immigrant workforce, many of whom can neither read nor write. That makes it very hard to find a job that does not involve heavy physical labour, like a clerical post for example. But even in a case like that, my priority aim is to keep them in the firm. That makes partnership – and mutual trust – with the worker concerned, the remedial treatment sector and company decision-makers essential.
Can they always be kept in the firm?
FL — The tendency of firms to hyper-specialize can obviously be an insuperable obstacle to redeployment. And without wanting to downplay the impact of the current economic crisis on businesses, I do sometimes see employers using the crisis as an excuse to avoid redeploying workers whose health prevents them from doing the things they were hired to do. The point is that redeployment asks questions about work organization, and that’s something not all employers are happy to do.
DR — With this crisis, my feeling is that people are putting their job before their health. I am increasingly faced with patients who refuse point blank to be signed off. They don’t want to stop work for fear of losing their jobs. Some say: "Just give me something, but I want to go to work tomorrow." And those who agree to a medical certificate want to be signed off for the minimum possible time. This isn’t something you found ten years ago.
The European working conditions surveys report a huge rise in musculoskeletal disorders (MSDs) and the emergence of psychosocial problems. Are you finding that at the sharp end?
FL — You could say I’m beset by MSDs morning, noon and night. The first thing to say is that these are multifactor conditions. Apart from the biomechanical factors related to forceful work like carrying heavy loads, organizational factors like just-in-time working play an important role, as do psychosocial aspects. Effectively tackling work-related MSDs means acting on the way the work is organized. We have to persuade employers to look again at their work organization, reminding them that it is in their company's interest to have healthy workers. Surprisingly, the same awareness-raising job also needs doing with shop steward committees who often instinctively negotiate with employers for financial compensation rather than a change in working conditions.
DR — People don’t want to know that their working conditions are what are giving them a bad back. They shut out the thought because admitting it would lead to the worst-case scenario of losing their job or a promotion. And GPs are seeing that its managers as much as manual workers that are in denial. Sadly, by the time they have to face the fact that their work is affecting their body, it is often too late to do anything. Where psychosocial risks are concerned, on the other hand, my patients more readily admit the link with their work but don’t always distinguish between things like pressure, overwork, stress, harassment, etc.
Work-related cancers often don’t appear until after workers have retired. Are there any procedures for exchanging information between works doctors and GPs to uncover their occupational origins?
FL — None. Occupational health records are normally kept by the company occupational health service, but the workers most at risk tend to be those who regularly change jobs. It would take real detective work to track back their entire career, let alone identify exactly what carcinogens they were exposed to. Theoretically, the Occupational Diseases Fund (ODF) should do this, but sadly we are a million miles from that in reality.
DR — In thirty years of practice I have never had a retired worker ask me to make an application for recognition of an occupational disease, and few enough from active workers.
FL — On this specific point, you should know that in Belgium the occupational doctor is not notified when a worker applies for recognition of an occupational disease through their GP or a specialist. Nor do we get told of the Occupational Diseases Fund’s decision. We’ve been pressing for it for a very long time, but clearly, the ODF is not that way inclined.
The unclear work-related origin of many cancers is obviously not helping to get movement. Do we need to break down the barriers between public and occupational health?
DR — Information campaigns on health at work would certainly help make patients and even doctors more aware. I have found that TV advertising has a significant impact. Information campaigns run in recent years by the authorities to cut antibiotic consumption had a significant effect on people. Many of my patients are now pressing not to be given antibiotics if they aren’t strictly necessary. Work simply doesn’t feature in health education campaigns in Belgium. From a political perspective, it’s obviously easier to guilt-trip people by playing up lifestyle factors like smoking, diet, etc. People who feel guilty are more manageable...
FL — I think we need to keep a distinction between public health and occupational health because of the real risk of turning occupational doctors into a sort of "healthy living" guru along the lines of "eat so many portions of fruit a day", "quit smoking", etc. I’m not denying that this kind of message is useful, and I do put it across, but I don’t see it as the occupational doctor's main job to come out with them. I am sensing a strong trend towards getting works doctors to carry out this health education duty at the expense (within a fixed budget) of looking for primary prevention measures in the workplace. Personally, I won’t do it, but I recognize that some of my colleagues are more supportive of it•.