At AOHC, attendees, please welcome AECOM President, Dr. Robert Bourgeois. Thank you and good afternoon. I hope you all are enjoying the fantastic sessions at this year's conference. At last year's virtual AOHC, we began what I hope will become a tradition of bringing everyone together each day during the conference. This year, in line with the AOHC theme, we're going to hear about perspectives on the future of occupational and environmental medicine. I'm delighted to introduce Dr. Judith McKenzie, who will moderate today's session. Dr. McKenzie is the Executive Director for Health, Safety, and Environment for Johns Hopkins University and the Johns Hopkins Health System. She is also Professor of Medicine and Division Director for Occupational and Environmental Medicine. She was previously Professor and Chief of the Division of OEM, Department of Emergency Medicine at the University of Pennsylvania, Perlman School of Medicine, and OEM Residency Program Director. She is active in clinical practice, research, and education. An epidemiologist trained in both occupational medicine and internal medicine, Dr. McKenzie received her AB from Princeton University, her MD from Yale University School of Medicine, and her MPH from Johns Hopkins, where she also completed her OEM Fellowship in the Epidemiology Research Track. Dr. McKenzie has authored over 130 scientific publications, and her research focuses on work as a social determinant of health, OEM exposures and illnesses, heat-related illness consequent to climate change, cost of work disability, graduate medical education, employee wellness, and COVID-19 vaccine hesitancy. Please join me in welcoming Dr. Judith McKenzie. Thank you, Dr. Bourgeois, for that introduction. Our panel is going to talk about the perspectives on the future of occupational and environmental medicine. I feel that this theme has been going on throughout the day, throughout the days we've been here, and I think we're at a point where we really need to think about our future. I'm joined in doing this by Dr. Berenji, Dr. Ghidadi, and Dr. Emmett. I call her Mani. So Mani is the Chief of Occupational Health at the VA Long Beach Healthcare System and Clinical Assistant Professor at UC Irvine School of Medicine and Public Health. Dr. Ghidadi attended his first ACOM meeting in 1974, long before it was called ACOM. He is past president of the college and author and editor of over 300 scientific publications, including the forthcoming book, Occupational and Environmental Medicine, Protection of Health at Work and in the Community. This was also produced with the assistance of ACOM and will appear at the end of the year. And last but not least, Dr. Edward Emmett is Professor Emeritus at the University of Pennsylvania Parliament School of Medicine, and he has diverse experiences, including founding director of Johns Hopkins Center for OEM and Chief Executive Australian National Health and Safety Commission, developing national occupational safety standards and policies. He was also commissioner for the Workers' Compensation Authority, vice chair of the ILO-WHO Coordinating Committee for Occupational Health, and is author of over 200 scientific publications. He is currently actively engaged in the training place program at University of Pennsylvania as well as community engagement with environmental hazards such as asbestos and bushfires. So I'm going to start the talk. I hope I know how to advance the slides. Let's see. I may need help with this. Thank you, Mani. Okay. Okay. So this session, we're going to go through various topics. The future of OEM, what are the salient features that we need to talk about? And this is what, as a group, we decided on. I'm going to present the presidential task force findings, which was entitled The Future of Occupational Medicine, Facing Emerging Infectious Threats, JEDI, which is Justice, Equity, Diversity, and Inclusion in the Workplace, The Future of Telehealth in OEM, Sustainable Sustainability in OEM, and The Future of Work. We'll end with a panel discussion. Can everyone hear me well enough? Okay. So, what are the learning objectives? To assess how OEM has changed and the need to be agile to continue to meet the needs of workers and the changing workplace, to discuss ensuring the viability of OEM, to explore evolving competencies necessary for the OEM residents as well as practicing physicians, to highlight the role that we played in strengthening health systems and of contingency planning to meet infectious occupational threats of the future, and to recognize elements in the changing nature of work and how to meet the challenges. So I'm going to start the first three topics. I have no disclosures to make. So the future of OEM task force was actually appointed by Dr. Beth Baker, and I was the chair. I had the honor of being the chair, and I divided the group into three sections. One section was to look at funding and create a position paper, which we did, and I'll tell you about it. Another section was for medical students and residents, the future for them, and another section was mid-level providers. So in terms of the position paper, we thought about what's our value proposition? Who cares? Who are we? What do we have to offer? What's the value to be delivered, communicated, and acknowledged by OEM as our specialty is broad? We decided that we have a comprehensive skill set that's pretty unique, that will protect health and well-being of employees and the broader public. We can work in multidisciplinary teams. Without that, we could achieve nothing. We're able to pull teams together and integrate the expertise of the stakeholders in the group. We're able to manage work-related illnesses and injuries effectively. We can reduce workers' compensation costs. If you ask any internal medicine or family medicine or any other specialty, what's workers' comp bill, they have no clue. We can identify and mitigate workplace hazards, making the workplace a healthier place for employees. We improve worker health and safety through communication. We communicate with the employees, with the employer, with labor. We're sort of that interperson. We provide population health management, workforce wellness, chronic disease management to reduce health care costs. And this is general health care costs by reducing, say, hypertension or diabetes or whatever's in the workplace through our wellness programs that we provide. We have the public health, employee health, population management, and epidemiologist skills to address outbreaks such as the pandemic. We saw Dr. Issachari win an award for her vaccination, set up vaccinating thousands of employees. We provide expert opinion on complex causation, return to work determinations. We can recognize the interplay between work, home, community, and integrate all of that to take care of our patient. And finally, we know how to create surveillance programs, whether it's for burnout, which I actually gave a talk on last year, or whether it's flu vaccine, whatever it is. These are the current competencies of an OEM physician that was published in 2021 led by Natalie Hartenbaum. Take a look at these competencies. They have been updated four times, 1998, 2008, 2014, and then 2021. What will their future competencies be? Will we have to add competencies next year? How long will these last? And you can read for yourself this clinical, law, regulations, environmental health, work fitness disability, toxicology, hazard recognition, disaster prep, health and productivity, public health management. So are these broad enough to cover what we do, or will we have to update them in 10 years or sooner? So this position statement looked at the state of our training right now. Even though we have high satisfaction, lowest burnout, we have lots of jobs available now, especially since the pandemic, and we showed our expertise, yet we still have a shortage of OEM physicians. And this has been going on since 1991, when the IOM, now called the NASEM, published a report about the shortage, and it still persists. We had over 40 programs in the 1970s, and now we have 24. So we're not actually helping the shortage anymore, we're actually getting worse. In terms of shortage, there has been research done to see why do we have the shortage, and there are various reasons, one of which is funding. NIOSH has been funding these residency programs, but that has dwindled over the years. We have HRSA funding, but it's only for two to three programs, only two have had continuous funding since 2008. We have 24 programs, two are funded by HRSA. Most of us do not get institutional funding, most residences do not get institutional funding. Some get funding from the VA, partial funding for their program. And then there's the Occupational Physician Scholarship Fund, which was very robust. From 1994 to 2004, it's no longer solvent. Military programs get military funding, and the Center for Medicare Services do not fund our residences, although they fund other residences that do hospital work. So one is funding. The second reason is limited visibility of our specialty. And the ACGME, there is some activity, and this should improve, I'll mention that a little bit later. Also, we've heard, at least this session today, and probably elsewhere, curriculum. We're not in the medical school curriculum for whatever reason. There's no room, it's too much basic science, there's no will, we're not required, and we're hardly there. And whenever we're there, it's because of efforts by individual OEM providers who kind of push ourselves in. Because of that, many are unaware of occupational medicine until their mid-career. And there really, until more recently, there was no opportunity for mid-career physicians to train. But we do have a train-in-place program at University of Pennsylvania, and the founding director is right here on stage, Dr. Edward Emmett. It's reproducible, and there's also a train-in-place program at Yale for PAs that I read about. And there's also a general preventive medicine train-in-place program with the government, but we were the first. So in terms of training positions for residents, so this also helps explain why we're short, right? So this is 2001 to 2022, we really haven't increased, in fact, we've decreased slightly. And in fact, half our spots remain unfilled, which you heard Senator Cassidy mention at the video yesterday. But other programs have grown, internal medicine, family medicine, they have grown, but we haven't. In terms of how many board-certified specialists we have, currently we have about 3,068. It went down a little bit from 2019 from 3,168. I won't call it a trend, because I only have two numbers that I could rely on, so that's all I'm presenting. In 1999, it was 2,442. In 1997, we had over 200 newly board-certified physicians. Then as of 2006, we dropped to under 100 and remain under 100 per year since then. Less than half of physicians providing OEM services are not boarded in occupational medicine, they may be boarded in other fields, and some are double-boarded. But we have some positive inroads, it's not all woe is me. Since the COVID-19 pandemic, we've had increased attention. In addition, because of the collective and collaborative leadership from our peers and leaders, we're on the cusp of having the ACGME list us separately as a specialty. Right now, we're listed under preventive medicine, so occupational medicine and aerospace medicine are listed under preventive medicine. Once we're decoupled from that, if a medical student or a resident or anyone wants to search occupational medicine, they can find us much more quickly in terms of training. Right now, they have to go through several layers to find us, and they don't find us most of the time. Also, we're being rebranded as OEM by the ACGME, rather than OEM. We have been OEM forever, but we have been listed by the ACGME as OEM. There's also funding initiatives. You saw Dr. Bourgeois presented Senator Cassidy's noting that money has... I don't know whether it will actually come to fruition, hopefully, but that's what was on the video. The task force medical student group that I had mentioned earlier, led by Nath Jones and Kathy Kirkland and Marcella Targino, created a PowerPoint presentation. People have asked me in the past, do you have a PowerPoint I can use? Well, now there's one on the ACOM website. You can take it down and put your face on it, do whatever you want to do with it, present it. I've used it. It's really good. If you think of Credit Where Credit Was Due, this was previously produced by ACOM and they sort of updated it, so that was done. But the wins don't occur in a vacuum. I just want to make that clear. It may seem like things happen magically, but they did not. It was leaders just constantly, and us constantly working to improve our visibility. I like the phrase, a steady drumbeat of activity, so persevere. So call for action. Even though we have limited funding, we're still amazing. Our leaders in academic health centers, clinical practice, corporate medicine, regulatory agencies, government agencies, public health departments, insurance agencies, consulting, but the nation's need for formally trained OEM physicians is not being met. I would submit that we're all ambassadors of our specialty, and let's just keep trying to raise the awareness that I've seen throughout this conference with a steady drumbeat. I'm going to switch a little bit and talk about what we call JEDI, Justice, Equity, Diversity, and Inclusion. So much discussion has been going on addressing systemic racism and advancing gender equity, I think also with the death of George Floyd. I think rather than saying, oh, let's do something because we feel so bad for these people who have microaggressions or whatever it is, I think JEDI is important overall towards retention of workers for everybody. It's expensive to replace years or decades of expertise, and we do have experts in this. There are several organizations, such as the AAMC. They have toolkits that we can actually pull from their website and adapt their programs to have programs within our workplace. We don't have to start from scratch. There's a lot of research gone into it, so if we're not experts, we don't have to feel like we need to be an expert. We can actually use other people's work, which is out there and published. I just emphasize providing a workplace where employees feel valued and feel like they belong. This will increase retention, reduce attrition. Studies have been shown to do that, and it helps address one of the whys that employees leave. With a great resignation, this might be something that we should pay attention to. So the recommendation that I have pulled off is set an organizational agenda around belonging. Have structured programs to engage employees. Create affinity groups intentionally. If people like fishing, do a fishing affinity group, like whatever it might be. And then maybe invite experts to facilitate. You're not an expert. I'm not an expert necessarily. I'm presenting what I read, right? I tried to find an expert to do this piece, but I couldn't. So invite experts to facilitate groups. And for mentorship programs, an older person with a younger person, more experienced person or less experienced person. Create a mentorship program that you can create, and maybe have training for your mentors. We're not born with knowledge of how to mentor, right? And promote camaraderie at work with intentional exercises. Structured programs are associated with better belonging and less attrition. Systemic change takes systemic action. One of my colleagues who's an expert in JEDI, who I spoke to before this talk, I loved what she said. The sense of belonging is everything. And I hear that all the time. Just feeling like you belong. Your blood pressure goes down. Your pulse goes down. You feel so much more well, right? All this wellness we're talking about. And these intentional activities are associated with reduced feelings of isolation, and promote social support, which is associated with less burnout. And one of the models I like with social support is a Carr-Second-Johnson job demand control and social support model. And basically, in a nutshell, I mean, there's a lot of literature around this, a lot of research. But in a nutshell, wherever you fall at your workplace, if you have social support, your well-being is better, regardless if you're flat and having the same challenges. Social support helps you. And OEM physicians, as we know, have one of the lowest burnout rates. And we did a study on the AECOM membership, some of you may have completed the survey, and we did ask some social support questions. And we found that those who ascribed to having social support were less likely to have burnout. And this is the table, these are the questions we asked. And this is more a pictorial representation, where the odds ratio is less than one, if you have social support of burnout. So according to AAMC, I like this quote, to accelerate discovery and improve health, medicine needs equitable and inclusive environments in which all faculty, staff, administrators, and learners feel welcome, safe, and valued. That women and members of marginalized groups face systemic problems such as racism, bias, harassment, disrespect, and isolation. This action plan seeks to create more inclusive, equitable environments so they can better attract and advance a diverse workforce and improve the health of all people. So I'm going to switch one more time, kind of running through this. And we have other topics, which we'll finish in time. Facing emerging and infectious threats, the pandemic. The future of OEM, pandemics are our future, from what I understand. That's what the experts tell us. So disease and illness have plagued humanity from the very earliest time, and have increased since the move from agrarian communities, now with climate change and geographic distribution of infectious agents changing. We did a session on that yesterday. Widespread changes, trade as well, has distributing infectious agents. Larger cities increase contact with different populations, and animals and ecosystems will increase this. The good news is, though, that healthcare improvements have helped us better, make us better able to handle pandemics than we did, say, 100 years ago. And this slide just shows some serious viral outbreaks of the past 100 years. I just took this information off the Johns Hopkins website, which shows for the U.S., coronavirus deaths are around a million, right? If you look at the Spanish flu in the U.S., it was around 675. So our coronavirus deaths have actually gone beyond the Spanish flu deaths. And globally, we're at about around 7 million, which I think is very impressive. But this is just sort of context for you. Then I looked around to see what's been going on. What have we been doing as a society? We keep saying, let's prepare for the next pandemic. You hear on the news, pandemic preparedness. What are we doing? So I looked at the White House plan, and I took some excerpts from it. Basically, it says that the pandemic has exposed fundamental issues. They talk about public health and the need to increase public health funding and strengthen the public health workforce. I would submit that we are the public health workforce. Let's see what can be done to strengthen us. As devastating as the pandemic is, there's a reasonable likelihood that the next one will be soon and worse. So that's not encouraging. Unless we make transformative investments in pandemic preparedness now, we will not be meaningfully prepared. Again, there are important lessons to learn from COVID-19, but let's not fight yesterday's war. Let's not fall into the trap of fighting yesterday's war today or in the future. And before the next pandemic or biological threat, we need to respond to any possibility faster and even better. And then they talk about cost. They say the cost of preparing for a pandemic will actually be less than we spend on missile defense and preventing terrorism. So it sounds to me like there's a will there. I don't know if there's a concrete plan, but I did see this. The WHO last week announced that G20 has agreed to a global pandemic preparedness fund of $10 billion per year and $50 billion over five years to be housed at the World Bank. So there has been some agreement to actually put money aside for pandemic preparedness. During COVID-19, we all played a human's role in our response in the US to make the environment safer for employees. And collaboration, one of our skills, multidisciplinary groups, collaborating with others, because we can't do everything ourselves and we need different expertise to do the work. So we vaccinated people. We tested people. We did contact tracing, exposure assessment, return to work determinations, and long COVID presence. What will we do to prepare for the next pandemic? What will we as occupational medicine providers do on ourselves to prepare? I was tasked with preparing an institutional action plan that spanned two health systems, the Johns Hopkins Health System and University of Pennsylvania Health System. And it was approved by the deans of both Dean Jamieson at Penn and Dean Rothman at Hopkins. And the plan I produced was basically to look at best practices at both vaccine clinics. And what I found is that the main hospitals with guiding leadership in the very beginning, starting a month before the vaccine dropped, they were able to, we were able to plan, I was at Penn at the time, such that the first day the vaccine showed up, we were able to give the first dose. And we gave 60,000 doses together at both health systems within a month. 70% of the health system was vaccinated in four months. There was hesitancy, so not 100%, but certainly by the fall of 2021, when the mandate arrived, 95% were vaccinated and the other 5% either had exemptions or exceptions. Based on these employee health clinics, I was a medical director for the Penn Clinic and I was instrumental in creating and scaling it with a group, obviously, and I'm sure many of you could say the same thing. So the employee health clinics occurred first, and the patient and community clinics were then based on the employee clinics. So I think we were leaders in that. And also at Hopkins, the employee health clinic was the model for the patient and community clinics, which then went on to give hundreds of thousands of vaccines. And as of now, both health systems have actually given almost 2 million vaccines. So what I did was I looked at the best practice highlights and operational excellence with clear priorities and goals, collaborative leadership with all the stakeholders, including us. A lot of times we get left out, but I think with this pandemic, they're looking for expertise and that's what we had. So we were part of the team. Patient-controlled nursing, IT, IT is key to efficiently schedule people and so on and so forth. And also strong authentic leadership, leading by example, continuous improvement. Dr. Emmett, actually, I've worked with him for many years, and one of his favorite terms is relentless pursuit of continuous improvement, so I stole it and I like it. Flexibility and resilience, keeping up with the current science and guidelines, adapt them to the culture of your organization, and find experts. If you don't have them within your institution, go outside. You need experts. To be a highly reliable organization, you need experts, not just your friend across the street because you like them, you need experts who know how to do the work. Strategic thinking, communication, innovation. I think the biggest lesson for me was embracing ambiguity. Half the time, the CDC kept changing guidelines. We didn't know what was going to happen next. We think the pandemic is slowing down, it's not. So we had to embrace ambiguity and make decisions real time, rather than wait for all the facts. So we had enough facts, then we had to use analytical thinking and their judgment to make the decisions real time. So I used these best practices to develop a theoretical financial readiness plan for future preparedness. And what I did was, in the beginning, it was 15 minutes to give one dose, and in a few weeks, we were given doses at five minutes, and IT was really crucial in helping us to do this. And so to administer a scalable module of 10,000 vaccines, how long would it take? If you give five doses, if you give one dose every five minutes for eight-hour days, in eight days, you can give 10,000 vaccines at the cost of $29.95 per vaccine. This actually beat Maryland commercial pharmacy benchmarks, where they actually charged $33 to $37 per dose of a vaccine. And I looked at other benchmarks throughout the country, and we did beat them. So employee health clinics can actually do well, in terms of giving these vaccines. So a scalable module of 10,000 vaccines will cost $30,000 for 10,000 vaccines in eight days, using best practices. So next steps. Fighting a pandemic is like fighting a war against time. You don't know when and how the next challenge will present, so we need to be humble and flexible, right? We might be fighting tomorrow's war with today's knowledge, because we think we did it right this time, but things change. So we had to be flexible and humble and know how to pivot. Knowing who will do what, when, and with what resources is critical. I mean, right now, we've done so many things, the return to work, the contact tracing. We have a lot of knowledge. Are we just going to let it die, or are we going to do something with it? So add a pandemic preparedness plan for vaccine administration to your institution emergency preparedness plan. A preparedness plan is something that you can do, immortalizes best practices, put funds aside. The G20 said they're going to do it. The White House said they're going to do it. I don't know. Maybe we can talk to our leaders and say, hey, can we do that? That would make it easier for if we have another crisis we're not reeling, we say, oh yeah, good, I have this funding, and I have a plan, even if it's not the perfect plan for whenever the next pandemic hits. And create a best practices checklist for all the things that we do. Having a vaccine preparedness plan within an emergency preparedness plan for your institution might be a good idea. So that's my presentation, speed of three topics, and now we will go to Dr. Berenji. Thank you, Dr. McKenzie. So I was given the privilege of talking about telehealth and OEM today. I have no disclosures related to the subject matter of this talk. I'm very passionate about this subject. Clearly, a lot of us were kind of thrown into telehealth practice over the last couple of years, especially those of us who are full-time clinicians. So I just wanted to provide some perspectives about what I've experienced and what does the future hold. So again, no disclosures pertaining to the topic here. So at least when I was at Boston Medical Center, I actually did do a number of these telehealth consultations with my patients. Many of my patients at Boston Medical Center were people of color. Many of these folks did not know English. Trying to navigate the space when we had little tools available to us clinicians was an interesting time, to say the least. I still remember that day on March 13, 2020, when we had to go virtual. And I actually got redeployed to urgent care. So not only did I actually have to take care of COVID patients in the clinics, but I actually had to maintain my clinical practice and OEM virtually. And initially, it was all primarily audio. You can imagine doing patient consultations via phone. I mean, it's just a very limited medium. And we had issues getting translators and trying to talk to these folks with limited capacity. It was a very frustrating time, to say the least. But luckily, we were able to get the video component. We actually had a video platform embedded within our Epic or electronic health record system. And honestly, that really changed the game for me. Being able to see my patients in their home, understanding what was happening, where they were in real time. I actually found it to be a very enlightening experience, because I'd never actually had that opportunity to see patients in their home. And you actually can glean a lot of take-backs from that. So clearly, the pandemic has taught us a lot in terms of telehealth and the potential applications in occupational health practice. Telehealth patient monitoring is an area of very strong interest. Having patients have access to some of these tools, like a blood pressure cuff, for instance, or a pulse ox, or ways to be able to track the heart rate. I mean, these are things that we can incorporate into our physical examinations. And we can actually develop robust assessments, because we actually have metrics. So this is a very exciting development, I think. So I'm just going to talk about a few general trends. So McKinsey and company actually came out with some great reports looking at telehealth usage over the last couple of years. As you can see here, you can see there was an exponential rise through February into May of 2020. And then it kind of plateaued into the latter part of 2020 into 2021. So clearly, telehealth is still being utilized. It's just that now there's discussions about how do we incorporate this particular media in the way we deliver patient care. Again, this is from the McKinsey report. We can see that, by specialty, psychiatry and substance abuse clinics really kind of ran with this. And we can see that most of our colleagues in psychiatry, psychology, they really are incorporating this technology into their day-to-day practice. And if you look at their literature, they really have embraced this technology. And I think for psychiatry specifically, it's really been a game changer for them. As you can see, some of the other surgical specialties, clearly it's not a conducive media to be able to do telehealth consultations because clearly you need to be able to physically exam these folks. But there's a lot of utility in specific fields. So I wanted to share a couple of findings from CMS as well as the HHS folks looking at Medicare beneficiaries' use of telehealth in 2020. So I'm just going to summarize the basic highlights of this study. So they were able to identify that many Medicare beneficiaries were able to utilize this technology. But unfortunately, there are disparities by racial group, by ethnic group, as well as the rural divide. Many of these folks who come from communities of color, as well as those folks who live in rural areas, had limited access to high-speed broadband. And that really limited their ability to use telehealth. And if you look at this HHS study, they actually did a cross-sectional survey of telehealth usage among specific participants in the community. And again, the main thing that came out of it was a lot of people were using telehealth. They liked it. But unfortunately, there is still a digital divide. And again, communities of color and people living in rural communities were the most impacted. So trends in occupational health. The Kaiser Family Foundation has done an excellent job looking into telemedicine and usage and looking at how employers actually like using this media. So this is the 2021 report. I'm just going to highlight a couple of things. So if you look at section 13 of the report, they actually look at employer practices, telehealth and employer responses to the pandemic. So as you can see from this slide, we can see that firms, you know, small firms, larger firms, we can see over the last five to six years. There's been a greater incorporation of telemedicine. And if we look at this particular slide, we can see that among firms that were offering health benefits. You know, what do these particular folks, you know, think about this particular media? And if you actually look at this, I mean, everyone really appreciates the fact that telehealth provides that ability to connect with your provider at your convenience. And again, looking at firms that were offering telemedicine health benefits, we can look at the structure of the firms that provided these benefits. And you know, no matter what the size, telemedicine offerings were something that a lot of these employers were giving their respective employees. So let's talk about trends in work injury care. So this article came out in 2021 looking at Concentra. And again, I'm not getting paid by Concentra. This just came out in a particular article. But they actually have been able to incorporate telehealth since 2017. And a lot of other commercial clinics out there that offer occupational health services have seen the utility of telehealth in being able to assess worker injuries and be able to triage accordingly. This JOEM article came out in the last year, and I just wanted to highlight the fact that there has been recognition that there are disparities. And I think that's a common theme of this presentation. Disparities, especially among people of color, racial and ethnic disparities, and again, that rural divide. So hopefully as we start to learn more about these topics, we can try to strategize about how we can broach the digital divide. And just a couple of slides here focusing on telemedicine patterns of use and reimbursement. This report came from the Workers' Compensation Research Institute, which is based in Boston. So again, I don't want to belabor the point, but clearly there's been an increase in utilization of telehealth services, really starting from the start of the pandemic back in March of 2020. You can see this graphic here. There was literally an exponential rise in these services. And I'm having a hard time seeing the slide, but essentially this is really looking at a state-by-state breakdown of the 20 or so states incorporated within this WCRI report. And this is looking at a cost breakdown in terms of CPT codes and what percentage of telehealth services offered by work injury clinics and occupational health providers were paid. This is a busy slide, and I apologize for that, but really I want you to focus on the top panel of this slide. So really this is looking at parity between in-person and telehealth services. And across the 20 or so states incorporated into this report, we can see that over the last year there has been parity in terms of what's offered in terms of payment for an in-person visit as well as for a telemedicine visit. And there's currently a lot of debate in Congress about how to approach the parity topic. And if you didn't know, there's actually an American Telemedicine Association meeting happening as we speak in Boston. So I'm kind of curious to see how this discussion is going to entail, because I think it's going to affect our bottom line, how we provide worker injury care to our respective clients. So the future of telehealth and OEM. I think it's going to incorporate a lot of different technologies, being able to meet patients where they are, incorporating some of those remote patient monitoring tools that we now have at our disposal, setting standards for how we're going to capture that physical examination via telehealth, and then really the parity and reimbursement piece is key. I talked about this in my previous presentation earlier today about the future of virtual occupational health. And this is a graphic that my colleague, Dr. David Stearns, who's not here today, he kind of put this together. But really what I want you to focus is that there are a lot of patient inputs that we have to incorporate into the virtual visit. And how we capture those metrics and how we're able to make decisions based on those metrics, utilizing the video to do the physical exam, and then being able to disseminate the appropriate medical treatment is going to be vital. And there's actually a presidential task force focused on the virtual occupational health clinic. So it's exciting to see where this is going to go. So conclusions, just a couple of bullets here. Rapid advances in telehealth technologies, applications, and utilizations have markedly increased in the last two and a half years or so. Many patients and employers see the utility of telemedicine. And telehealth usage is not uniform. Those who lack reliable access to high-speed broadband, for instance, and other telecommunication devices are at a disadvantage. So being able to address those disparities is key. And then last but not least, telehealth reimbursement rates and making sure that there is parity between in-person and telehealth visits. Thank you. I think I could squeeze by. All right. I'm sorry. Go ahead. Okay. Thank you. Are you good? How do I start my presentation? It's fine. Ah, good. Before I begin with my own perspective, and by the way, the only disclosure that I have is that I bear some responsibility for the current state that ACOM is in, and for that I take considerable credit and also apologize, but I think that we're in a much better place than we were when I was president. And I'm also the author of a book that is not for sale at this meeting called Health and Sustainability. Before I talk about my own perspective on the future of occupational and environmental medicine, I'd like to respond just a little bit to the Sappington Lecture. I thought the Sappington Lecture was a very good exposition of the current state, the future challenges of public health and preventive medicine. I don't think it really said a whole lot about occupational medicine and occupational environmental medicine and the situation that we find ourselves in. Well, thank you. I do not believe and have never accepted the assertion that we are a subspecialty of general preventive medicine. We're not. The way to understand occupational medicine, and by the way, I'm well aware of the long history, and I've written about this on many occasions. We have responsibility in a particular field of the workplace and the environment which has its own constraints, its own support systems, its own funding mechanisms, its own requirements in terms of our clinical acumen. In other words, the best way to think of occupational environmental medicine is as a system, not as a specialty. Individual practitioners move around within the system. Some practitioners are not certified specialists, and that's okay. That's perfectly fine. The point is the role that they fill, their understanding of the total system, and the degree to which they contribute to the big picture. So I think that that, I wanted to say that at the beginning. In terms of the perspective of occupational environmental medicine, I think that we have a pretty clear idea of who we are now. I don't think we did in the past, but I think we definitely do now. And I think that credit needs to be given to Mark Upfall for his pioneering work 15 years ago in producing a set of competencies and a set of themes that put down in black and white exactly what we do and exactly what our limits are. So that we could go to any specialty and say, this is us. I also think that Phil Harbour deserves a call out because of his work that described the career pathways and what occupational environmental physicians actually do. That it's not just an illusion that we go back and forth. It's not just an illusion that we have a primary, tertiary, and primary, secondary, and tertiary levels of care and management on both the individual patient and the population site. You can see it in the data. So I think that we are much clearer in terms of where we are than we even may know that. And I'm sorry if other specialties in other areas are having an identity crisis, but that's not us. I think that it has been said accurately and astutely by past presidents of ACOM. Warner Hudson once said that occupational medicine is public health for people at work. I think that that's one view, more on the population side that I hardly embrace. The other is Catherine Mueller's statement at the beginning of her presence, which I thought was deeply profound. We protect the health of the people who make our world and keep it running. Just think about that for a minute. And I'm going to return to that in the overall, the broader theme of sustainability. First of all, let me talk about risk. Because the concepts of risk and the concepts of sustainability are sort of central to my view of where we are going as a specialty and as a field of practice. I think that's important not to limit ourselves to thinking of ourselves as a designated specialty. We're also a broader field of practice, some of which is not recognized under the specialty, although that's better now with our name change. Understanding risk management, I think, is key here. That for population health in general and for occupational health in particular, we have always been about reducing disparities. We have peaks and valleys in the levels of risk defined by occupation, defined by environment, defined by where people live. And traditional public health has been all about flattening the disparities and removing them. Environmental health, however, takes a somewhat different tack. When you, for example, treat water quality, you do it for the entire population. You're not reducing it for certain groups the way we do in occupational health. So you're reducing the risk for everyone. Lowering the legs of the table. Increasingly, these days, we are in a paradigm in which people do not accept risk as a viable alternative at all. The idea of what risk is acceptable is flying out the window. What we see now are people who are saying there should be no risk attached to this particular chemical, no risk attached to this particular project because risk inherently is unjust. It is imposed by someone else. And therefore, some of the basic concepts of environmental justice have spilled over into this area and the public is not accepting of risk any longer. So when you talk about ecosystem health risk, it's not tolerable anymore. And you also see that in legal practice and in a role as an expert that the tolerance for risk is declining and the legal system is basically saying that if there's a consequence, well, it's on you. It's on whoever created the consequence. The public isn't very impressed by the idea that there is some level of risk that is accessible and irreducible. Now, is that a false paradigm? It's a social paradigm. So whether it's false in the sense of being realistic is somewhat beside the point. It's a question of that the public increasingly rejects the idea of an imposed risk. And they do it for many reasons. And some of the reasons are listed on the left and I won't go into detail. The concept that I want to leave with you is that part of the way forward for us, as well as for public health, but they've got to do it in their own context, is sustainability. Sustainability is not just a buzzword. Sustainability is not something that is greenwash for companies that want to look good. It actually has a history. It has a philosophy. It's got a legal context. It's got a, it has meaning. It comes from the modern ecology movement, but also it has deep roots in, actually, if you're at all interested in this, in forest productivity and sustained yield. It's a whole long story there. It comes from Germany. The value of sustainability, in my opinion, is strategic as well as the fact that it's simply the right thing to do. Sustainability turns a negative threat into a positive commitment. In other words, we can say, we're all going to die because we're all polluted and the world is warming beyond human tolerance. That may be true, but we don't, that doesn't necessarily have to be our motivating factor. In fact, it's demotivating because of the anxiety that it provokes. What we can say is we're in this together and we have a shared interest in making this come out right. We can create partnerships and we can work together so that not only can we avoid catastrophe, but we can create a world that we would really like to live in that is better than the one we had before. So sustainability has this transformative effect of taking a negative, turning it into a positive, and lifting people up and avoiding the headbanging that takes place when you're in constant controversy about on a particular issue. It reduces the resistance that you encounter, the pushback. It facilitates acceptance of environmental protection and also occupational justice within the workforce, which is a micro environment and fits into this. Now, those of you who have public health backgrounds and who, in fact, straddle between occupational medicine and preventive medicine may find that this sounds very familiar. The reason it sounds so familiar is that it is also the playbook of health promotion. What health promotion did starting 30 years ago and peaking about 20 years ago was to take issues of health and to say, we've been concentrating on risk factors and we've been concentrating on things you can't do and hazards to health and the bad things that come from human behavior, and we're going to concentrate on group behavior to enhance behavior, to make everyone feel good, to participate. In my opinion, this is what sustainability does on a broader social and ecological sense. It turns this idea of a negative that's holding you down and that is weighing down society into a positive that can be a transforming force to lift you up. Now, what is sustainability? I've been using the term without defining it. Well, it's a neologism, I grant you, but it comes from deep roots. It comes from sustainable development and it comes directly from a critically important commission that was chaired by a physician for the World Health Organization in 1987. The term sustainable development was largely an economic and economic development term, but it's achieved broad application. Basically, it's about meeting the needs of the present, but without compromising the ability of future generations to meet their own needs. Now, why is sustainability so important on a strategic level? It's because people have bought into it, including the corporate sector. This is a situation where we have an unexpected ally, namely the business sector. It works for us. It combines pressing global issues with local environmental remediation and reconstruction. It changes the fear and the guilt of the negative message to a positive, and it is nonpartisan. So it gives us an opportunity for a less confrontational approach and a new platform for action. And it's, as I say, the business community is behind it and it's not just greenwash. It's not just an effort to paint over bad practices. Now, on a global level, the World Health Organization, actually the entire United Nations system, sorry about that, have bought into the idea with 17 sustainable development goals. These sustainable development goals are organizing the agenda for all United Nations agencies, and they are 17 priority areas which are intended to advance to end the workplace as well as the environment and end society. And notice that number three, sorry, well, there's plenty of opportunity, as I'll show you in a moment, for occupational health to participate. And here they are. I think that this is about as good an agenda as you can get for how we can help and work toward decent work and economic growth as well as good health and well-being through the employment relationship. Sustainability has been so widely accepted on the corporate level that McKinsey, which was mentioned actually earlier in the previous presentation, has stopped tracking the number of sustainability programs. This used to be one of their major annual reports. Now, they've said, well, it's now permeating businesses, so we're not going to report on it any longer. Many companies now have sustainability managers, usually the big ones. One of the big advantages of chief sustainability managers and so forth is that it does not depend on corporate responsibility. Corporate responsibility was brushed aside with the philosophy of shareholder value to our detriment as a society, I believe, but sustainability is based on a different logic. It's not largesse from the employer. It is a shared survival strategy, if you will. So we're now seeing the advent of these positions as normative behavior in large enterprises. To keep track of this, there is a system that has emerged, which is now across the board hardwired into accounting and the reporting of large companies. This is called the Triple P model or the Triple E model, depending on which you prefer, and it has to do with regular reporting to shareholders, regular reporting to the community on environmental sustainability and what a corporation has done, economic sustainability and social sustainability, including health. Here's the Triple bottom line for Disney. Disney reports every year on progress that they've made in helping the people, helping planet, helping profit. And the associated business plans for each. I think that sustainability also fits in very well with continuous quality improvement, which fits as a standard management tool with the way that managers get things done. And I think that that is one policy that will drive us forward, although we don't have time to explore it. So what are the implications for occupational environmental medicine? Well, if we talk about continuous improvement, we can link OEM to management priorities. It fits with sustainability, it fits with continuous quality improvement. We can view the workplaces as a sustainable environment and workers as a sustainable resource. But even more than that, we can think of workers and their communities as the whole reason for sustainability. Because after all, why are we engaged in all of this? If we're not helping people, and people are workers and people live in the community. It also helps us position ourselves for the circular economy, for the economy that is neither wasteful nor inefficient, and which ultimately does not lead us down a path toward progressive degradation. I personally think that the circular economy, which we talk about as being desirable now, if we don't adopt it and move to it with great alacrity, it will be imposed upon us because we will be facing one disaster after another. So I think that the circular economy right now is what we desire. Circular economy in 10 years what's imposed on us because it's critical. And then I'm going to also make the point that it sidesteps the constant battles that we face, setting standards and so forth, which we then have to revise every five or 10 years because we have new science and we know that what we thought was protective wasn't after all. So my advice is make friends with the corporate responsibility, I'm sorry, the corporate sustainability officer in your organization, because if this kind of operating procedure does not exist now, it will soon. And finally, what does it mean for us in occupational environmental medicine? It means an economy that works, safe and decent work, a minimal footprint on the earth, which can only take so much abuse. And then it comes back on us because nature does not have a sense of humor. It means a sustainable workforce, sustainable productivity to make sure that our economy doesn't collapse, sustainable operations, including resilience built into our systems, and eventually occupational justice. The whole concept of environmental justice has been transformative in environmental health and in environmental management. We're going to see this in the workplace as well, with new attention to what is fair in the workplace and who is assuming the risk and who benefits from the assumption of risk. So I'm going to stop there. Any one of these slides can be an hour lecture in itself, and I know that Judith is quivering with anxiety that I might elaborate on any one of them. Do you want to answer? Thank you, another perspective. It's really nice to talk about the future and the future of work. And the reason is that it isn't until next week that people will be able to say you were quite wrong. And so I really relish this opportunity. So if I can have the, I think there are some slides, have I got to do this? Oh goodness. Good on you. Yep, well, we're all about work in occupational medicine. Next slide. And it's many things. The results of work, diseases, hazardous work, fitness, accommodations, contributed to productivity, work organisations, all the laws and regulations, demands on the worker. That's what we've done. And it's been continually changing occupational medicine. If we look through the history, we see that around 1700, Ramazzini described prevention, the illnesses, diseases, and the ergonomic problems of 69 different occupations. It was apparent way back then. And in the 18th century, on a ship, the second most important person after the captain was the ship's doctor. And the ship's doctor was really the public health person, treated people, looked after the social conditions, and he made sure that there was a productive crew to go through the whole trip. Because if there wasn't on a sailing ship, they were doomed and all were dead. And really that tradition of the ship's doctor, I think goes on in military medicine, and it goes on in a lot still of occupational health. But work changed with the Industrial Revolution, and we had the industrial surgeon. You know, if you go to Gary, Indiana, for example, to the steel plant or where the steel plant was, there are as many other places. It was a two-storey building just at the entrance to the plant, and that was a hospital. That was where the industrial surgeon fixed all the repairs, the broken bones, tried to save those who were burnt or killed, eventually in bad shape, and that was the form of industrial medicine needed because of the enormous safety problems, and then we had chemical and biologic hazards as we introduced more sophisticated chemical, physical, and engineering things, and that gave us a lot of our current practices, toxicology, surveillance, biomonitoring. All these arose out of the chemical and physical hazards, and workers' compensation increased, and we had the ergonomic problems, but the 21st century brings us a new revolution in work. We have the digitalisation. We have sleep disturbances. We have the effects and the stress of dealing with different algorithms that measure everything we do, and that has really changed work, and it's changed the people we'll have to work with. We'll have to work with sociologists, psychologists, maybe the neuroergonomist. It's a really different use, and through all of this, we have been very diverse. We have a large number of unusual hazards, specialised work environments, which we're very good at, and a large range of workplace cultures, and all of those mean that our practices are very different. If I go to an ophthalmologist, anywhere in the developed world, a general ophthalmologist, the office is pretty much the same and the type of patients they see are the same. In occupational medicine, everywhere you go, the practice is a little different and the workers are different. But as work is changing, business is changing. We have now a few dominant technology giants, and they're likely to remain, unless they can be split up, because they grow by networking. The more customers they have, the more data they have, and the more they dominate the market. Totally different to all the other industries, where the big conglomerates are disappearing. Sears, General Electric, General Motors are in bad shape, and they're declining, and what's working in the rest of industry are niche businesses. People who concentrate not on doing everything, like the old GE, but on a niche business that they dominate, where they're successful, they're specialised, and they're agile, they're concentrating on keeping up to date with that. I've noticed something, and others have noticed, that what businesses now want is they want a product. This is important, I think, to occupational medicine. Perhaps the best illustration is my son, who's majored in business and logistics. He worked for a company that rented out equipment, and he said to me, it's terrible, he said, I go to all the agencies and our dealers, and they're all talking about the wonderful equipment they have, and they've got the newest of this, and the latest of that. He said, I go to the customer, and all they want is a hole in the ground. They're actually put off by all this other highfalutin stuff, and they feel it'll be expensive. We have, I think, in occupational medicine, what is the hole in the ground we're making, or the hole in the ground we're filling, and provide a complete solution to those needs, because they, in this current environment, they are the types of organisations that are succeeding. The other important factor that's happening, some people have referred to it, I refer to it as a restlessness of employees. Not everyone gets a new job, and some of those that do aren't happy there, but employees are restless. When I talk to business owners and senior executives, and I ask them, what is their number one problem, what's their fear? It's always the same. In this environment, it's losing key employees. We'll lose the key employees, and a business will decline. That's something, and they're always interested in what occupational medicine, and how can we help in that productivity, and how can we keep in that retention. As business changes, the workforce is changing. We've talked a little about the demographic shift, diversity, single parents, two working parents, ageing workforce that can't work quite as much, and they need more help to work, but have got that valuable experience. We've got the young worker now who wants the work-life balance. They don't want to sacrifice everything to a career. They want the balance. The digital economy is making haves. They're the people that Robert Wright called symbolic analysts, the people who work at the computers. They can work anywhere in the world. If you know enough, and you're specialised in something, you get a great salary, you can work anywhere, you can have a wonderful life, and the have-nots, the physical labourers, the people who can't work. We have something to offer, and something we must give, I think, to both groups. The unslept, the poor sleeping, rich, but stressed individual, and the have-nots who we know are dying at increasing rates from their suicide, liver disease, drug addiction, and the like. Then there's working from home. Other strange things happening in society, trust. Who we trust is changing. We're no longer trusting, and surveys have shown this, we're no longer trusting governments. We're no longer necessarily trusting the standard professions. We're actually putting more trust in what comes through the employer. I think that's an opportunity for occupational medicine. Then the world is changing. The two black swan events, the pandemic, we all know about that, and the Stalinist era invasion of Ukraine. One of the things they have done, in the same way as they are both changing globalisation, and they're making on-shoring more attractive. On-shoring means America rebuilding a lot of those industries, the dangerous, the hazardous things that we exported, because now you can't trust. The pandemic has shown you can't trust getting goods in that were the cheapest to produce way over there somewhere, and they don't arrive, or they're delayed. They're not just in time. The national security need, the Russians have shown us, we've got to have stuff close at hand. We can't be dependent for our security and our future on things that are far away. Key things have got to come back to America. These are all changing. The next slide. What do we do in all of this? I think we have a unique combination of skills. We're not better than anyone else in any of the components of that work, which people have talked about, but we have a unique combination of skills. We also have many competitors. I believe the future, I like this Ampep as a future. I think, first of all, we've got to be adaptable. The world is changing in so many ways. It's just like the biologic evolution, survival, the fittest is the person who adapts. We've got to maintain research and a knowledge base that supports our professional contribution that is distinct to us, because each group, each professional group in life has to have some unique knowledge and area that they're better at. That has to come through, I think, our research and our data. We've got to market our product. Not with a great big campaign, but I believe we have to market by visibility. Another difference from the poor old person in preventive medicine, they do not have a mission and the values. They're not clear what they do. It's very clear what we do. Our mission, our values are clear. What we don't have is enough visibility. I think all of us have to work on increasing our visibility wherever we are. That can be with friends, with patients, by stuff on social media, messages about prevention. Our field is fundamentally interesting. Work to people is interesting, but we've got to be more visible and hopefully more visible than others in dealing with this. We've got to produce products that meet needs, not just services, but how do we meet the whole need of people, embrace technology and promote. We have wonderful examples. We have all sorts of dangerous work in the world that can be done safely. We have all sort of contributions that we've made to getting people back to work and things. We must promote those. We must tell those stories. The sociologists tell us that people learn best from stories. We have to put our story out there. Thank you. Thank you very much to our panel for those talks and all these various topics regarding the future of our specialty. Now it's time for questions to the panel or comments you might have, ideas you may have as to our future. That was very provocative. Thank you. I have a question actually for Dr. Berenji related to the parity issue. I was wondering if you've given any thought to the new coding rules, the new E&M coding rules and the doing away of having to count widgets of physical exam components and whether or not that provides an opportunity for using the intellectual component of the telemedicine visit instead of what normally would be an encounter face-to-face. Yeah. Thank you for your question. Honestly, I've thought about it, but I think we need to kind of understand how this coding is going to be incorporated into a day-to-day practice. I think it's a very exciting development. I need to learn more about it, but I do think that there is a lot of potential with utilizing a coding system that's user-friendly for the clinician. So if we're able to understand how we can incorporate that into our day-to-day clinical practices and at the end of the day, it's really about ensuring that we're providing high quality care at the best cost. So I think, I honestly think that there's still a lot to be said. So I can't really provide a definitive, you know, yay or nay at this point. But from what I see so far, I think it's a step in the right direction. Hi, my name is Luke Meese. My question is about the JEDI, I love that acronym, by the way, the Justice Equity, Diversity and Inclusion. I can see, you know, and I can imagine like how in my own clinic and kind of my own residence program, definitely things we can do to improve that. For the panel, what are some things that you would suggest that we can do for the workers that we're taking care of where we may not have as much direct influence on their workplace? We may have some indirect influence, but it's not, you know, a space or a group of folks that we necessarily have a lot of direct contact or direct fluency. How can we still advocate for and promote those principles for those patients and workers that we're seeing? I suppose it's questions for me, unless the panel has any other responses. So I think, you know, the phrase that resonates most with me is belonging is everything. And we all have unique workplaces. So I think, you know, it's sort of a structural thing. You need to find out what it is at your workplace that people need. So it takes work. If it's all remote workers, or I don't know exactly what situation you're talking about, but maybe even do a survey or do some background work as to what your people need and what would help. Would an affinity group be helpful? If they're all remote workers, would an affinity group be helpful for them? You know, to say specifically what to do is difficult, but whatever you think might help to bring people together, have a better sense of belonging. Yeah, I'll give you an example. I was at a conference last week, and a professor from China who was an immigrant, and she kept saying, you know, I have an accent, blah, blah, blah. She created a research group for budding researchers who were having, I wouldn't say difficulty, but yeah, difficulty. And it was a safe place where they could discuss their research, discuss their grant proposals. And she was an expert in that, so she worked on their grant proposals. And the acceptance rate went from 5% to 40%. And the biggest thing people said was, I feel like I belong in this group. I finally feel like I belong at work because I have a group. So you know, it just depends on your culture, where you are. But belonging is everything, and that could be a good place to start. Any other comments? I think that the first thing is being kind and respectful. And if you are kind and respectful to people, that word will get around. It'll get around quicker than you could ever have said it. And then I think this issue of bringing groups together is very important, but how you do that really depends on where you work. If you work in a corporation, I think you could have a little advisory group, or a group that you bounce ideas off, that's diverse and have different representatives. You may have an opportunity to go around and to talk to different groups. It just depends where you are, how you construct it. And sometimes it's a group who speak a different language. Sometimes it's a group of people who are new. There are many ways to do it, and that depends on the circumstances. Thanks, Ted. Go ahead, Anna. Yes, thank you. This is in regards to your question, if I understood it correctly. My name is Anna Nobis. I'm an assistant medical director at Vanderbilt. And our department of medicine, under which we fall, created a diversity, equity, and inclusion committee. And even though I do not have experience necessarily talking about those topics as an expert, I volunteered because I wanted to do something. And even though it's an imperfect attempt, it's a sincere attempt. And that has been very, very rewarding. And I've, you know, when my colleagues who are also minorities, when they find out that I'm involved with that, they share personal stories. And you just become more aware of what some of your colleagues experience on a daily basis that you may not have known about before. In addition, our division chair has invited my colleague and me to lead journal clubs and anti-racism discussion groups. And this coming Tuesday, we're going to be reviewing articles about how to not be a bystander but to be an upstander. And teaching, especially attendings, how to intervene on behalf of their residents when there may be microaggressions or outright racism. And not just let those go. So just some examples. Thank you. Thank you for that. Excellent points. My name is Carl Auerbach. I'm in clinical practice in Albany, New York. Excellent presentation from all of you. But I want to touch on one point that Dr. Bugatti mentioned. Dr. Young's talk yesterday struck me as more general. It wasn't just preventive medicine in that sense. I think it could be translated to occupational medicine in many ways, except as Tia has pointed out, we have a great number of opportunities, much more perhaps than general preventive medicine. If two things. One, we embrace and grab it. And two, we have enough providers to do it. And that, I think, is going to be one of the biggest problems moving forward, that I hope that occupational medicine doesn't get lost in the funding and support for preventive medicine in the more general sense. So it's a challenge. We're going to have to face it. I hope we can solve it. Thank you for that. I don't disagree. I think that Carl, of course, had a very long and distinguished career in the boards and in postgraduate education, and is surely aware of the elephant in the room, which is that there's been a longstanding tension between the objectives of occupational medicine and the objectives of general preventive medicine and public health, to the point where there was, when the boards were created, there was a controversy about which should survive and which were eventually adopted. So there's actually a subtext to all this that goes way back, and which is, in a way, counterproductive to keep dragging up, but it's important to understand where some people are coming from. I think that what gives occupational environmental medicine the advantage, and where general preventive medicine often struggles, is that we have a framework within which to work. We have a framework for payment. We have a framework for reaching workers. We have a framework for delivering services within a corporate or a clinic network structure. And above all, we have a very powerful glue that holds it all together, and that's the employment relationship. Preventive medicine has none of that, and so they have a very difficult road to hoe, because they're dependent on underfunded, largely local health departments, to really make a difference or to move the ball forward. And that's part of the shadows that you see in the background when the subject comes up. I personally am persuaded that the critical thing is for us to poise ourselves to act quickly and constructively when the time comes, because I personally believe that medicine in general, organized medicine, is not coming apart at the seams, but it's showing a lot of strain. And the strain is going to eventually cause gaps, eventually gonna cause opportunities, the reorganizations of medical specialties, compensation arrangements, authorized treatments, and so forth. And I think that at that time, when it occurs, and I'm not holding my breath, but I think that there's a chance that this will happen, we can step forward and say, we have an integrated model, we do population as well as individual medicine, we have that capacity, we have an understanding of the environment, and we are a model. We're a model of what an effective preventive medicine, small P and small M, especially could be within the healthcare system. And I think that when and if that day comes, we should have a strong organization in the form of ACOM, we should have clear practice guidelines in the form of the APG, we should have a definition of our specialty in the form of the competencies, and we should be ready to step forward and say, here's your model. I think there's another factor here. I agree with that, but I think there's another factor here, and that is that in general, occupational medicine may not be the best choice as an intern. And there is a body of opinion that people with some experience then going into occupational medicine with a lot of medical maturity, and that this is a very good career. The senator referred to this yesterday. And I think that we might also keep in mind that that has served us very well in the past, might in the future, and that might require and might be able to get a separate funding stream because it will be less expensive. And that will make a lot of difference in the decisions that are made about medical manpower. So I think that's another very important aspect. Thank you. Dr. Hodgson. Michael Hodgson. Interesting panel, great work. I wanted to go back to something that Dr. Ghadadi just said, namely occupational medicine has a framework. And over the last two days, there's been a lot of talk about the environment, climate change, and the like as driving our succession potentials. The framework for occupational medicine, employment, workers' compensation, so the regulatory and the economic basis of the specialty is well-defined. If you do that kind of an analysis for the occupational medicine side, where do you go for environmental medicine? Where do you deal with lead in the home, moisture and asthma? You know, all of the things that don't currently have a formal framework, and how do we as a specialty deal with that? I think Dr. Emmett laid out one potential with his statement just now, but I wonder whether that's worth a more formal discussion. Well, I don't have my hearing aid in, so I'm going to answer the question I heard. I've written quite extensively on the relationship of occupational medicine and environmental medicine. It's my opinion that it's one unitary field, but it's like an egg. One side is pointing and the other is round. It's polar. And on the occupational medicine side, it's very well-developed because it has a payment mechanism. It has all the advantages that we discussed earlier, and it has a fund of knowledge that's essential, that's essential, that is not completely shared with preventive medicine. It has to do with processes and the organization of work. The environmental side has its own dynamics, and certainly there are issues that are now becoming apparent in ecosystem health issues, like climate change, that are stressing that model as well. But environmental medicine doesn't have a payment mechanism. It largely has to work either through lawsuits or through administrative actions. So it is more akin to public health, broadly in terms of policy and regulation, and it has less to do with the individual, although clearly environmental threats do affect the individual, but they tend to affect the individual in different ways on a population basis that are not so easy to diagnose. So I think that the two intellectually are two ends of the same stick, so to speak. But I think that the occupational medicine side is much better developed because of historical factors and frankly the payment system. I think there's another thing in the development. A lot of occupational medicine arose, became strong, workers' compensation certainly, because there was a movement outside. Medicine can't do these things. We can't pay ourselves. There was a movement from the labor force and then also compromises with business that produced that. We, I think if you're interested in making a case for this particular environmental health doctor, the environmental movement and those concerned about this will have to embrace that need and express and lobby for, I've been in national politics, lobby for a doctor who can understand those concerns and can understand those things, can at least talk to what the things are and not dismiss the patient. And that is, I think, the best chance to really establish a force and a payment mechanism. Thank you. Go ahead, Scott McClellan. So I just found a penny from my thoughts on this topic. So, two points. First, with respect to the way doctors are paid right now. One way we're paid is by seeing patients. The potential for the healthcare organizations for which we work to be paid to keep populations healthy means that those organizations need to pay attention to those factors which affect people's health. And we have some expertise in that area when it comes to environmental health and populations. So, I think there is, I mean, I work in an organization that kind of came up with the idea of accountable care organizations and invested big time in the flip to getting paid per capita. And it didn't happen. But I still think it could happen. So that's one, I think, potential where we could actually get paid by healthcare organizations to help keep communities healthy. The other thing is I'm privileged to co-chair a action collaborative that's a spinoff of the Roundtable for Population Health Improvement of the National Academy of Medicine or Science, Energy, Engineering, and Medicine. And this action collaborative is around engaging business in improving community health. And in fact, and this is to your point, Tia, around sustainability. Many businesses are investing in improving community health for many reasons. One, because that's where their employees live. And those are the employees who then get on their health plan, et cetera, et cetera. So there are all of those reasons. There are also all the reasons to attract employees to the community to be their employees, it needs to be a wonderful community with green space and all of those other things, a beautiful built environment, et cetera, that attract people. So I think the other way we can be paid to do environmental medicine is actually by employers who we have been providing occupational medicine services for their employed workforce, but now they're concerned about the dependents and all the employees to be. And even broader than that, the community in general. There is, our website has a number of archived webinars that have been case histories of businesses that have done this around the country. Michigan, forgetting the acronym right now for their group. But they, not the ACOM group, I'm talking about, this is an acronym for the business collaboration that have come together, and this has happened in Tennessee as well, where they said that the economic future of the community depends upon improving community health. And so, and this is true also in a Tennessee group that has done this. They've looked out to the future, and if they don't improve community health, the economic prosperity is gonna go down. So I think there's actually this other opportunity to get paid by our traditional employers in business to help them with that. That's a terrific idea. We'll take one more. I think we're out of time. T, did you want to respond? Yeah. Do you want to respond first, and then? Well, actually, what I wanted to do was to turn the tables, because clearly, Bob has as much experience as anyone in this room thinking about these issues. But what I was going to ask Bob was, what do you think of the Finnish model, where occupational physicians in Finland are actually fully trained in providing primary care internal medicine, and deal with occupation as part of that practice? In other words, it's seamless. There's not a divide between the two, and their practice encompasses that sort of adult health for the community, including their occupational needs? Well, I think that goes beyond my point, but I think it's a good idea. I mean, it gets to Ted's point, that I personally believe, and the point, actually, that Dr. Young is making. I think we need more clinical experience. And many of us, I mean, I began in family medicine. I got my board certification through a complementary path. And I thought it was a great way to enter the profession. And I totally agree with T, that I think, I mean, with Ted, that we really should be looking toward growing that potential for people who have life experience and medical experience, and then attracting them to the field. Great discussion. I'll try to be short. So a little feedback, and throughout the presentations over the last few days and today, we've mentioned in very good discussions about diversity, inclusion, and equity. And so obviously, it's part of the future, if we're thinking of the future. I think it's, I'd like to know if you think that diversity, inclusion, and equity, as it relates to AECOM, specifically, is it well-defined? Does AECOM understand, beyond what society looks at sex, gender, but actual political thought, religious diversity, being open to other people's opinions, as opposed to trying, and I think we're seeing a lot of societal reactions, somewhat of a boomerang. So my ask would be, does AECOM actually have a good definition for equity, inclusion, diversity? And what's, do you feel that you have a good idea of what AECOM membership is made of, and how important it is, or is not, to the membership? That's an excellent question. I'm actually not on the board, but from what I understand, it's a big priority for AECOM, and it's being worked on as we speak. So whether there's one already, if someone knows better, let me know, but I know that it's a big priority right now for AECOM. Yeah. Well, just to say that I worked on the Code of Ethics, and we actually came up with language in a principle that would fundamentally give the foundation for what AECOM should be doing, and certainly came along with a variety of actions that we've recommended. I don't know where that stands. I heard that it had not yet moved forward, and I'd love to. It's being worked on. I think, I don't wanna speak out of turn, but yeah. So there has been a lot of work done, and there are a lot of people who are quite anxious to move it forward. More to come, more to come. Rest assured. Will you take one more? I work at a institution where preventive medicine is very much in charge. They have pretty much all the leadership positions. They control all the money. OCMED is very much under preventive medicine. You've given an excellent presentation tonight about occupational medicine needing to be visible and adaptable, needing funds. I'm just wondering, to meet those goals, do you think it's at least partially needed that we have our own board and not be in a combined board with preventive medicine? That's, yeah, that's the latest hot off the press. Right now, the ACGME, oh, you mean the ABPM? The ACGME has, well, I think come July 1, if everything goes forward, the ACGME has agreed to decouple occupational medicine and aerospace medicine from general preventive medicine. So I don't know if I'm answering your question, but we're gonna be, under the ACGME, separate. We're gonna be OCMED, aerospace, GPM. We're not gonna be together anymore. So we're not gonna be under the ABPM? Well, the ABPM is the licensing body, right? And I saw the executive director, but he left, or he could answer that question. So under ABPM, it's gonna be separate exams. So right now, we do, the morning is preventive is GPM, and then the afternoon exam is OCMED, aerospace, or GPM. The morning is PM, and then split up into three. But going forward, it's gonna be three separate exams. So OCMED will have their own exam, aerospace will have their own exam, and GPM will have their own exam. We'll still be under the same board. I mean, the board has hyperbaric medicine, they have informatics. So we will be occupational medicine under ABPM, because we're still a preventive medicine field, right? I think T said small p, small m. But we will be our own person, yeah. Does that answer your question? You look skeptical, but I think it's gonna happen come July 1. Call me if it doesn't. You think that's a big enough separation? I think it's amazing that we even got that, because I know, I mean, I'm late to the party, but I know that other people ahead of me have been working on this for years. I know, including Beth Baker, and it's been, we've been working on this for years, and finally now, we're achieving it, so I think that's a really, really big win. Is it enough? I don't know, we'll see. You know, once we're decoupled, will we be more visible? Will students be able to find us in residence? I was in a session today, and someone said, I Google OCMED, I don't find anything, right? Occupational therapy. So once we decouple, the AMA will have us listed separately as well, and you know, we'll see what happens. If we need to do more work, then like a steady drum beat, we'll just keep doing more work, but I feel very positive about it, because I know it's years of work that went into making this happen. Thanks. Separate exams. I don't know if there are any other questions, but I think we have gone over our time. We thank you for being a wonderful audience, and I thank our panelists for their amazing talks and responses.

occupational and environmental medicine

future of occupational medicine

justice

equity

diversity

inclusion in the workplace

telehealth in OEM

sustainability in OEM

future of work

inclusive workplaces

COVID-19 pandemic

pandemic preparedness

telehealth in occupational medicine

improving community health