Among all medical specialists, physicians in occupational or general preventive medicine are most likely to be satisfied with their work-life balance and least likely to suffer from burnout, according to a 2012 study published in the former Archives of Internal Medicine. Yet few medical students know about this specialty, says Scott C. Jones, DO, MPH, the president of the American Osteopathic College of Occupational and Preventive Medicine (AOCOPM).
The overall field of preventive medicine includes general preventive medicine and public health, aerospace medicine, and occupational and environmental medicine. Most general preventive medicine specialists work for federal, state or local public health agencies or pursue careers in academia. Most aerospace medicine specialists work for the military, NASA or the Federal Aviation Administration.
Attracting more DOs than the other two preventive medicine disciplines, occupational medicine involves promoting wellness and preventing injuries in the workplace and assessing and treating individual employees for work-related injuries and illnesses.
Physicians who specialize in occupational medicine have many career options. They can be employed by large corporations in any industry or profession. They can be in private practice and contract their services out to other organizations. And they can run clinics that evaluate and treat workers from a variety of occupations and employers. Many employed occupational medicine physicians also do independent consulting work.
“I like the field because it’s wide open and you find yourself doing really interesting things,” says P. Lance Walker, DO, MPH, who performs evaluations in his Marietta, Ga., office to determine impairment levels from disability and to decide whether employees are safe to return to work after an injury or illness. He also performs onsite firefighter examinations for a number of fire departments, serves as the medical director of a power company, and teaches other physicians how to perform truck driver examinations in accordance with new requirements.
“Occupational medicine is fascinating,” agrees Dr. Jones, the medical director of corporate health services for St. Louis-based BJC HealthCare, Missouri’s largest employer. In addition to overseeing the health and safety of BJC employees, Dr. Jones directs three BJC occupational medicine clinics that serve the community.
Dr. Jones enjoys the detective work involved in occupational medicine, such as determining whether an ankle really was sprained at work rather than at home. While employees at times are deliberately deceptive, many conditions and injuries do not have obvious causes. “For example, an employee may believe he or she developed carpal tunnel syndrome on the job. But many people with carpal tunnel have other underlying health conditions, such as thyroid disease or diabetes,” Dr. Jones says. “The trick is to figure out what the underlying problem is.”
Occupational medicine specialists investigate worksites, as well as obtain thorough patient histories and perform physical examinations, to ascertain the causes of ailments and injuries.
“We’re advocates of the medical truth, not advocates for the employer or the employee,” Dr. Jones says.
Thomas Truncale, DO, MPH, became interested in occupational medicine during a rotation he served while completing his fellowship in pulmonary medicine. “Dermatological, neurological and pulmonary problems are the major complications that arise from the various kinds of workplace exposures,” says Dr. Truncale, who directs the preventive medicine residency at the University of South Florida College of Public Health in Tampa. “I find that intriguing. I also like that you have to wear multiple hats in occupational medicine. You deal with insurance companies, employers, employees, administrative staff, clinics and hospitals, and attorneys. Every case involves many different details. Occ-med is very intellectually stimulating.”
Occupational medicine is not only interesting but also a lot of fun, according to Dr. Jones. “Every day is a field trip,” he says. He has ridden fire trucks, welded materials on construction sites, climbed into airplanes and sampled many other adventurous occupations during workplace injury investigations and ergonomic assessments.
Specialists in general preventive medicine are also enthusiastic about their discipline. John T. “Tom” O’Connor, DO, MPH, of Marietta, Okla., practiced rural family medicine for several years before deciding to pursue a secondary specialty in preventive medicine and public health. In addition to spending 40 years caring for his patients “from birth to nursing home,” as he puts it, he served for decades as the medical director of his county health department.
“In my public health role, my focus was on community health, not individual patients,” says Dr. O’Connor, who recently retired. “I loved it. Preventive medicine specialists look at various interventions in terms of their effectiveness and help determine what should be included in clinical practice guidelines.” Pay-for-performance and quality-improvement programs, such as the Centers for Medicare and Medicaid Services’ Physicians Quality Reporting System, are based on the findings of preventive medicine specialists, Dr. O’Connor points out.
As did Drs. Jones, Walker and O’Connor, many physicians enter preventive medicine disciplines after becoming board certified in other specialties. But it is important for osteopathic medical students today to begin preparing for a career in occupational or general preventive medicine before finishing med school.
Preventive medicine residencies, which are two-year programs, begin in postgraduate year 2 and require a year of prior clinical training. Only one AOA-approved residency in preventive medicine currently exists—a dually accredited program in general preventive medicine and public health at the Palm Beach County (Fla.) Health Department. At present, this is the only preventive medicine program that will accept DOs who have completed just a traditional osteopathic internship or a year or more of another AOA-approved residency.
The Accreditation Council for Graduate Medical Education (ACGME) lists approximately 70 preventive medicine residencies, the largest proportion of which focus on occupational health. To gain entry into one of these residencies, osteopathic medical graduates need to serve an ACGME-accredited transitional year or a year in another ACGME-accredited residency program. This is an ACGME requirement for its preventive medicine programs that predates by many years the proposed changes to the ACGME’s common program requirements currently under consideration.
Prior to 2008, waivers could be granted to DOs with osteopathic training on a case-by-case basis, says Charles L. “Carl” Werntz III, DO, MPH, who directs the ACGME-accredited occupational medicine residency at the West Virginia University School of Medicine in Morgantown. But since then, the ACGME has prohibited such waivers.
“During the past few years, I’ve had several quality DO applicants I couldn’t accept because they had only AOA-approved training,” Dr. Werntz says. “Unfortunately, many osteopathic medical students are listening to their schools and choosing osteopathic programs without understanding the long-term career ramifications.”
Even DOs who are already AOA board certified in other specialties cannot be admitted into ACGME-accredited preventive medicine programs if they don’t have the requisite year of ACGME clinical training, adds Dr. Truncale, whose pulmonary fellowship was ACGME-accredited though he is AOA-trained and AOA-boarded in internal medicine.
“Unfortunately, they’re stuck if they don’t have at least 11 months of ACGME training in direct patient care,” Dr. Truncale says. The training year can be in any specialty but psychiatry, which doesn’t provide enough months of clinical patient care, he says.
The American Osteopathic Board of Preventive Medicine (AOBPM) does offer a certificate of added qualifications in occupational medicine that can be pursued by DOs with only AOA training who are AOA board certified in another specialty.
Osteopathic physicians who complete ACGME training in any preventive medicine discipline may become AOA board certified by passing an AOBPM board-certification examination in occupational and environmental medicine, public health and community medicine, or aerospace medicine. Most such DOs choose to become board certified by the American Board of Preventive Medicine but may seek AOA board certification as well to reach specific career goals.
As long as they meet the training prerequisites, osteopathic physicians are often desirable candidates for ACGME preventive medicine residencies, says program director Stefanos N. Kales, MD, MPH, who has admitted several DOs into his highly competitive occupational medicine residency at the Harvard School of Public Health in Boston.
“In general, the osteopathic physicians I’ve brought in are strong in musculoskeletal medicine,” Dr. Kales says. “Most work injuries you see on a day-to-day basis are musculoskeletal, so I think that background is really advantageous.”
Dr. Kales, who receives hundreds of inquiries about his program each year, can be selective about the residents he takes on. He looks favorably on applicants who have completed prior clinical residencies in specialties such as internal medicine, family medicine, and physical medicine and rehabilitation. He also is impressed by military medical service.
Although Dr. Kale’s program is accredited for 12 residents, he usually has six residents at a time—three each year.
Preventive medicine residencies are funded by the National Institute for Occupational Safety and Health (NIOSH) rather than CMS. As a result, says Dr. Kales, the funding is less consistent.
“If your program is Medicare-funded, you generally know how many spots you will have each year and pick the best people to fill those spots,” he says. “In contrast, we have to wait and see what our funding will be each year. We can weed down our applications and choose the best people, but then we have to make sure we have funding for each person before we can make offers.”
Dr. Truncale receives 60 to 80 applications each year for typically two or three openings, depending on funding. He seeks candidates who are genuinely interested in occupational medicine, which can be discerned from personal statements.
Dr. Truncale expects candidates to have passed all three steps of the United States Medical Licensing Examination or the Comprehensive Osteopathic Medical Licensing Examination of the United States. However, like most preventive medicine program directors, he does not require board scores to be above a particular percentile.
Applicants who have served rotations in a preventive medicine discipline always have an edge, program directors say. Osteopathic medical students can serve elective rotations at the CDC and NIOSH, as well as with many of the ACGME-accredited programs.
“Rotating with us is not required, but it is certainly encouraged,” says West Virginia Univeristy’s Dr. Werntz. “But we also view favorably applicants who have rotated in occupational medicine somewhere else. What makes a difference to us is that the applicant knows what occupational medicine is and is really interested in a career in the specialty.”
Much variation exists among preventive medicine residencies, although all require coursework in epidemiology, biostatistics and related subjects, leading to a master’s degree in public health. Tuition costs for the MPH or MSPH degrees are normally funded by the residency.
Dr. Kales touts the great opportunities for networking and research collaboration at Harvard’s occupational medicine residency, given the proximity of the Harvard Medical School and Harvard-affiliated teaching hospitals. “Our residents produce a large number of publications and have received numerous research awards,” he says.
In Dr. Werntz’s program, residents spend half of their last year working at the NIOSH office in Morgantown. They also spend approximately two months in the state’s capital focusing on workers’ compensation, one month in a corporate medical department, and one month in a community-based occupational medicine setting.
Residents serve an elective rotation in the final two months of the program. “Some residents go to OSHA to learn the regulatory aspects of occupational medicine,” Dr. Werntz says. “Some do international rotations. We’ve had residents go to Saudi Arabia and Pakistan to learn about their occupational medicine programs.”
Dr. Werntz notes that probably one-third of his residency graduates enter private practice, while the rest become employed. Those who have additional clinical board certifications—in internal medicine, family medicine or emergency medicine, for example—have more employment flexibility, he says.
Bright job prospects
Occupational and general preventive medicine specialists do not have to take call and generally have less stressful jobs than other medical specialists. “I work a lot less hard than I did when I was a family medicine doctor taking care of 40 to 50 patients a day and worrying about my practice all the time,” Dr. Walker says.
Occupational medicine physicians, in particular, are also well-paid. “From a business perspective, reimbursement for occupational medicine is much better than it is in many other areas of medical specialty,” Dr. Jones says.
And with many occupational medicine specialists nearing retirement, the job prospects have become bright.
“The median age in our specialty is 60-something,” Dr. Werntz says. “So there is a need for new physicians in this field.
“I’m not saying that all graduates of occupational medicine residencies get their dream jobs. But if they’re willing to do the clinical aspects of occupational medicine, the work is out there.”