So, really quickly, I'll introduce myself. My name is Mazel Winokur. I am a second-year resident at the University of Pennsylvania in Occupational and Environmental Medicine. And my goal here today is to introduce our two amazing speakers who are going to be talking about occupational and environmental health training programs. So, without further ado, our first speaker will be Dr. Sajjad Sawal. He is a graduate of Kuber Medical College at the University of Peshawar, and I apologize, Dr. Sawal, Pakistan. He earned a master's of science in aerospace medicine from Wright State University, completing his residency in aerospace medicine at Wright State University, and then family medicine at Latrobe Area Hospital, where he was chief resident. Dr. Sawal then went on to complete his OEM residency at the University of Pennsylvania, where he was also chief resident. He served as the medical director of Bay Health Medical before transitioning over to Penn. Currently, he's the medical director in occupational medicine at the Penn Presbyterian Hospital in here in Philadelphia, as well as the residency program director in occupational and environmental medicine for Penn. He's one of the only aviation medical examiners in the tri-state area, and his research accolades include working to evaluate interventions to increase physician under-representation in medicine in occupational medicine training. Our second speaker is Dr. Eric Wood. He's a graduate of the University of Utah School of Medicine, and he completed his master's of public health at the University of Hawaii. Before his foray into medicine, he was actually an industrial hygienist, so has been in occupational and environmental health for a very long time. He completed an appropriately long time. He completed residency training in family medicine in the University of Nevada and residency training in occupational and environmental medicine at the University of Utah. He's both board certified in preventive medicine and family medicine. Currently, he's the director of occupational medicine at the Rocky Mountain Center for Occupational and Environmental Health. He serves ... His academic responsibilities include education and training of both OEM residents, graduate students, medical students, and other health professionals. In addition to his clinical and education duties, he conducts research focusing on occupational health and wellness among commercial truck drivers, and he's appointed the inaugural medical fellow for the Federal Motor Carrier Safety Administration. In addition to all of his other duties, he also does clinical research in work-related musculoskeletal disorders, so you have great presenters today. Without further ado, I'd like to introduce Dr. Saville, who will be beginning the session. Thank you. Thank you, Mazal, for those very kind introductions. Thank you, everybody, and I first apologize for a little delay. I guess we were a couple minutes behind some technical thing, but we are back on, and we'll finish on time. What about the topic first, the rise and fall of OEM training programs? I was discussing this title with a senior colleague here a few months ago, and he said, what, are you talking about the Roman Empire? I said, no, but we have seen the rise, and now we are sort of, unfortunately, trending down, so we will look at from where to here, and then from here to hopefully back up on the rise, talking about the OEM programs. Now, so our objectives today are to assess physician shortages in the field of occupational and environmental medicine, and then learn about limitations in having an adequate number of physicians who are trained and certified in OEM, and then analyze the trajectory, or the trend of physician training programs in OEM. So it starts with sort of a false belief. Back in the early 80s, the Graduate Medical Education National Advisory Committee concluded that the U.S. was on the verge of a massive physician surplus. Maybe there were physicians, there were more physicians graduating, more med school students graduating, but it wasn't really a surplus. They probably did not take other things into account, like the population or how that number will be in the long run. So they pretty much stuck by that statement, like for the next 25 years or so, that was the understanding. The medical school moratorium for those 25 years put some roadblocks on, like, establishing new med schools, and also reducing the number of enrollees in the then-current med schools. A few years later, AMA, they had a consensus statement, and which was, like, supported by the Association of American Medical Colleges, that it was still a surplus. Now this is about 17 years after 1980, but then early 2000s, you know, that's when came the awareness that the prior projections were inaccurate. 2005, the Association of American Medical Colleges, they were the first to say that there is a substantial expansion needed in medical schools to have their enrollment up by 30 percent, and more recently, just a couple of years ago, the same association estimated a shortage of, like, up to 139, 140 physicians by the year 2023, so in the next 15 years from 2018, but this is more, like, for the primary care, and all specialties, actually, not specifically OEM. So if you look at the, some of the numbers and years I gave, and if you look at this graph, actually, it is a very true picture, like, if you look at 1980, you can see that what we called the surplus was at 1980, some measures were taken, and then there was more like a plateau, actually, downward trend, sort of a plateau, and then back in 2005, when they changed their statement or the projections, we started going back up. So we are heading in the right direction. The green line is the U.S. population over those 30 or some years, or actually 50 or some years. So the OEM physician shortages, now we, most of us know that OSHA came to birth 1970, soon after, and a couple of years later, NIOSH identified a shortage of 3,000 physicians in occupational medicine. Now, at that time, the population was, like, and the working population was in, like, in the 110s of millions, and then a little later, about 15 or so years later, then there was another estimate commissioned by the Institute of Medicine, the IOM, where they said about the same, like, 3,500 physician shortages. Not much changed, I guess, in those 17 years. I think there was at a minimum shortage of 3,500 specialists, and at that time, limited availability of training programs in OEM, well, at that time, it was only occupational medicine, but OEM or OEM, at that time, was considered a factor, limited availability of training programs. Then this other famous report, the NASAM, National Academies of Sciences, Engineering and Medicine, in 1991, that showed an additional need for 5,500 physicians, including, well, they generalize, they said, like, those who can do OEM, so it could be primary care physicians who are doing occupational medicine or have some competence in OEM, and at that time, the same report, it showed that the medical school curriculum only had four hours, on an average, in their four years of education, and this is not all the programs. This was, like, about under 60% of the programs, and I was in a different meeting yesterday, and there, the consensus was, it's two hours, not even four hours now. So the NASAM report, part of that was the Institute of Medicine, that committee recommended that all primary care physicians be able to identify possible occupationally or environmentally induced conditions, like injuries, illnesses, and make appropriate referrals, management. So they wanted the primary care physicians to see work-related injuries and illnesses, given the shortage of OEM-trained physicians, and then they said, like, they had a minimum standard of care, and actually, I was, like, what, 20 years ago, I was a family medicine doctor, doing 30% of my clinical time as OEM. I did that for a few years, and then, like, now, for the last 18 or so years, it's full-time OCMED. So at a minimum, to standard of care for primary care physicians, as you can see, to have some basic knowledge of OEM and how to take, like, the appropriate work, occupational history, and some role in workers' compensation, and the primary care physicians were more, like, into your routine health care insurances and so forth, and then some of the implications that work injuries or workers' comp diagnoses may have on, like, other health conditions or other health systems, other insurances, to keep that line between workers' comp and your other health insurance. And also, like, from an environmental standpoint, population health standpoint, to know when to report hazards to public health and relevant authorities. So that report, even though it was now, what, now 30 years ago, they offered six specific measures to alleviate the shortage of physicians in OEM. So increase interest in the field among students and trainees, something that, to this day, we talk about doing. I mean, not that we, there's nothing being done. It is there, but it's not as much as you would like to see. Establish a cohort of centers of excellence to train future teachers, researchers, leaders in OEM. That has been done in bits and pieces. I mean, ACOM has done a lot over the years. Then also integrate environmental medicine with OCMED training until, like, the late 1980s. It was mostly occupational medicine, but then the incorporating environmental medicine, funding for faculty development, support residency, and fellowship training. That also is, like, funding is a major constraint there. And then to explore and adopt new pathways to certification in OEM. And that we have seen. You know, if you, the ABPM, I think there's a different talk, too, during this conference about the different pathways to certification if you're not residency trained in OEM. So let's, we talked about the ABPM, the American Board of Environmental Medicine. So looking at, and these slides were shared with some of the program directors just a week or two ago. So these are very recent. The specialty certificates as a proportion of all specialty certificates in preventive medicine, or ABPM, about half are OEM, which is very encouraging. But what that 47% or about 50% means in numbers, it's about 3,100. So as of January 2023, there are only 3,103 occupational medicine board certified physicians in the U.S. So that includes new or recertified. And this is just the showing, like, those 3,100, but full credit to physicians who are doing occupational medicine and are not board certified in OEM. I mean, they are doing occupational medicine. So that number is not in the 3,100, but that probably is maybe another 3,000. I don't have an exact figure, but this is an estimate. So looking at the population, as you can see, we are at about, I'm sorry, this is the working population, and this is full-time and part-time. So we are at about 160 million. You project it to another seven or eight years, it's another 10 million. And then board certified OEM docs, 3,100. This is, again, some of the exam registrations. But I just want to, sorry, this is a small frame, but the orange arrows, which show the yearly number of occupational medicine physicians who get board certified. That's negligible. It's just around, under, about 100. So, and this is, again, another graphic showing, like, the yearly number of board certified occupational medicine physicians. And the lowest number, as you can see, was 2010, 60 were certified, new certifications. And then the highest number was back in the 1997. I actually approached the board and asking, like, why that big number, 229, in the year before and the year after was around 100. And so the, I would say the presumption is that that was the year where there was time certified or time limited certification was to end. So that was a little surge. And not that there were more trained OEM doctors that year. So we are, like, a near, well, the near retirement group, which is here, AMA defines as, like, age 55 and above, that age group. And so generally, overall, about 45% of all active physicians, all specialties, is 45%. And then this survey is from 2020. And it shows, like, the preventive medicine physicians, which we fall under, there's not no specific one for OEM docs, is 70%. And so this is a more recent survey. This is, like, 2022. This ended, like, what, December 31st, 2021. And it shows still, like, we are actually a little more now. So I guess we didn't have that many new ones. And that's 72%. I don't know what happened to the pulmonary here. They probably didn't survey. Remember, it was 90%. Maybe they were all in their 90s. So no comments. Probably they did not look at or put that in a different specialty, like intensivist or... All right. The programs. Timing okay, I think. See, looking at the number of OEM programs, and now we're talking about the residencies, OEM residencies. So back in the 1970s, like, late 1970s, 40 programs, actually 43, if you count three in Canada. So 40 programs. Of those 40, I believe three were, like, military-based, and the rest, 37 or so, were civilian. Remember, like, 1972, NIOS, like, to have more training programs. And that's where we went up to, like, 40. 1990, down to 29. 2023, as of today, 23 programs. And if you... Two military-based, so that's, again, selected candidates. So the civilian 21 programs. So we are, like, 50%, about 50% down. You can look at the trend in the graphic. But shouldn't complain as much, because look at the... The bigger illustration there is the OEM programs, year-to-year, for the last... In that, like, 18 or 20 years, the positions that are filled, generally, it's like 50% to 60% of the available slots are filled. Now, reasons, well, there's different reasons. Funding is two. Maybe some of the programs do not have funding, too. If a program is, like, four slots, they don't have funding for more than two. They're going to fill two. So it's not that we don't have applicants. It's that we cannot afford to train those applicants. By the way, the match, that illustration is from the match, NRMP match site. So there's no sarcasm there. Funding resources. So this, like I was talking about, that is a big obstacle. Now, some of the funding resources, unlike other residency programs, which is, like, you know, Medicare is huge, as many of you know. But for us, we don't have any Medicare funding. We have very limited federal funding. NIOSH has been big, you know, over decades, but they can support to some extent. HRSA is supportive, but then again, more for the general preventive medicine residency programs. In the last ten years, at least, HRSA has funded two to three occupational medicine residency programs and the bigger number like 20 plus is for the general preventive medicine programs. VA has a small portion there. Individual institution support, which again is not big. There was an occupational physician scholarship fund, OPSF, that was to through AECOM too was like managed through AECOM part of it, but that is obsolete now. I actually checked their website and it asked me if I wanted to purchase that website. So it's no longer there. All right, so why the OEM programs are declining and we talked about like the lack of adequate funding for training programs and then at the sort of the grassroots level, the med school, not like in your MS3, MS4 when you already decided where you're going, more like in the first year or even like pre-med when you're thinking of going into med school to have that concept of like occupational medicine, environmental medicine in the students. There's no formal mentorship in med schools or medical or even at the medical conferences on the specialty of OEM. At AECOM there is now mentorship available and in the last few years there has been work done. I said like at the grassroots level or like an MS, you know, earlier on in the med school because like this survey is from a matriculation student questionnaire for the med students and over the course of med school they did the survey before admission and then at the time of matriculation and a quarter of the respondents indicated the same specialty preference as indicated before or like earlier on, meaning three out of four changed their specialty. Once they, you know, found out more about like the their rotations, they saw they had electives, they saw different specialties, they had different mentors, so they, 75% changed their specialty. So why not? Why not OEM be part of the mentorship program or as a possible specialty? Well despite all this hardships and challenges, we, the OEM training programs, you know, help achieve occupational medicine practicing physicians, the proper training, the adequate training, help them achieve their board certification, and we're still producing excellent physicians and who work in different settings, regionally, nationally, globally, and in different setups. So in summary, we looked at the OEM journey of the training programs and the physician shortages over the last 30 or so years and we saw many changes like the surplus, the shortages, and the number of OEM programs, how many we have, how many we have now, some of the limitations on having more programs, having more residents, and our next presenter, Dr. Wood, is going to throw some light on like some of the strategies to help overcome our shortages. Eric, thank you. Thanks, and we'll take questions at the end. Okay, escape. I think I missed the last slide. How do I escape out of here? I'm not sure. I just wanted to show this last slide. This is a our residents class, most recent, who graduated, or soon to be graduating. How do I escape out of yours? I can't get my slides. Do you know what to do? It's not escaping. Perfect, thank you. Thank you so much. Cancel. Thanks, Saj. That was really helpful, really good. So I kind of retitled a little bit, if you'll excuse me, Saj, to the Rise and Rise of Occupational Medicine Training Programs, and thank you, and thank you for the wonderful introduction. That was really kind, too kind, really. Briefly, I'll give my disclosures. So as mentioned, I'm Director of the Occupational Medicine Program at the University of Utah and the Residency Program as well. I do a little bit of work for the Federal Occupational Health as a reviewing medical officer through my role at the University as well, some consulting work with WCF Insurance, and then I do have to credit the American Board of Preventive Medicine. I still hang on as one of the Examination Committee members, and for full disclosure, I just finished a nine-year term of the ABPM a couple of years ago, so I still hang on a little bit with some of this information as well. And these are a few pictures of our taking our residents to training, just to give a highlight of some of the kind of fun things that we do in addition to the academic and clinical training. On the bottom slide here, a group entering the Lila Canyon mine, coal mine, down in Carbon County, Utah. Coal mine is down in Carbon County. This is going up to, and some of you who were at WOHC or AOHC last year in Salt Lake may have actually been to this same foundry where we take the residents typically every year, a place where I do some medical directorship as well. And then finally, some of the fun stuff we do too. A lot of years we get to take the residents up to the local ski areas and see some of the really very, very interesting occupational health and safety risks at the ski areas for the ski professionals there. It's been a wild year in Salt Lake City for our skiing too, and we just had an avalanche cycle that closed the canyon where I work one day a week for over a week just because there were continual avalanches sloughing off the mountains. And fortunately no deaths there, but it's something that we unfortunately do see. So just a little bit of local color from where we are in Salt Lake City. So what I would like to do after Saj's introduction objectives is kind of mostly focus on limitations of having an adequate number of physicians. I want to give a brief overview of the current status of where we are in terms of what we know, what we hope we know a little bit about, where our status is in terms of practicing occupational medicine doctors out there. A little bit more in addition, some redundancy with what Saj gave already in terms of the model of training programs and some of the issues we have relating to recruitment and funding for residents coming into the programs. And then moving on to the pipeline issues of this is where I'm really glad to see such a big audience because I think this is an area where we all need to get involved in and how we can continue to grow our specialty, keep it from dwindling because it is kind of this issue that's overriding all of us at the whole profession really. And then finally I do want to do a little bit of a plug for a little bit of what goes on to the training programs to helping support the faculty and program directors because really so much of it depends on the continued recruitment of people into these positions and roles. As you mentioned I have had a few years under my belt so I may not be here forever. So we don't know too much about the active state of occupational medicine provision professionals out there in the community. A lot of what we know came out of this great survey at NIOSH Commission back in 2010 or so, published in 2011, the National Assessment of Occupational Safety and Health Workforce. And in that study basically what they did was they kind of reached out to the community at large, the leaders in all sorts of industries across the nation, to find out what their anticipated needs were for occupational health professionals moving into the next five years at least. And from this survey we learned that the expected need for occupational medicine physicians, and again looking at all occupational health professionals but specifically we'll cone in on the occupational medicine side of the house, is about 500 doctors over the next five years of time. So almost a hundred OEM graduates per year was what were the expectations was. There was a wide confidence interval on that but this is kind of the average what we're looking for. So what did we expect for how many would come out in the next five years of time? And already we're getting behind the curve on what the needs are. And this over that expectation was there'd be about 75 OEM graduates. That was projected in 2010, 2011. What we're really seeing now is about we get about 50 graduates per year. I mean that's really the rubber hits the road right now is there about 50 graduates from all the combined residency programs in the country. So we're obviously really short of what the targeted goals were. And again kind of Saj already kind of pointed this out a little bit as well but from ABPM sources we know that there's about 3,000 active board-certified occupational medicine doctors currently. This is 22 I think. And and again kind of the comments here that Saj I'll just point out again. So time limited about 1,700 of these so-called time limited graduates. And essentially that's everybody that graduated after about 1997, 1998 who then became board-certified and have to continue all the all the requirements with the ABPM to maintain your certification. Then we've got quite a bit of doctors 1,300 or so who are in that non time limited group. So typically these are people who are more senior, older. They don't have to perform all the requirements. And and the numbers are a little bit maybe inflated for active practicing doctors because again a lot of these people once you're non time limited you can continue to be a board-certified diplomat so long as you pay your dues and you keep a license. So you may not be practicing much if at all at that point. So really these numbers are probably maybe inflated for the actual true number of practicing board-certified occupational medicine doctors. And then kind of further reflecting this again Saj already pointed this as well mean age of our profession and board-certified 61 and over 60% are over 60 years of old. And then and you can see over here too in the far side med talks is faring even a little bit more senior than that with 80% over age 60. So that definitely needs some spike in the numbers there as well. We know from that great study from IOM back in 2015 or so that we as a profession generally do really well in terms of burnout and career satisfaction. Judith McKenzie and her group looked at this and I think 2020 published the prevalence of burnout in occupational medicine physicians. And in this even with our you know great satisfaction that we're at least we tout at least when we're doing our recruitment for medical students about 38% age 56 on her study were experienced to some degree of burnout and some some areas a little bit more than others. So government military 48% and private medical groups 36% or 46%. We can see the consultants seem to be faring best so a lot more control over I guess their day-to-day existence maybe. So what are we doing in occupational medicine? Many of you may remember back in around 2010 or so Phil Harbor going around and passing out surveys to find out what we all did for our day-to-day jobs. So Dr. Harbor published his career path in occupational medicine and at that point we still recognize again this is probably 15 almost 13 14 years ago now that clinical activities remain prevalent in most people's practices. It certainly starts that way for most people in the beginning of stages of the first year of work about 97% which was an increase from previous eras of going into clinical practice. And within that most people have a career arc where they change their practice over time. 40% change from clinical to non-clinical duties and in the next 10 years at this point most had anticipated some transition in their career paths from a clinical role to less clinical work more consulting type work and more administrative type work I think. So future of occupational medicine again I don't know if Judith is in the audience or not but I'm putting several of her papers up here and her work up here. So what are the future expectations? This is from 22 published in JOEM. Multidisciplinary residency training programs are providing that fit for producing leaders so it's a broad-based training program that really helps align them with their future career goals. And how what that means is in terms of career pathways is again many people coming out right away from the residencies are going into those clinical practice roles. A smaller number are typically going into academia and I'll get the true numbers that we're seeing from the past year at least later in the presentation. Corporate work as well as a lot of government nonprofit attraction out there as well. So most people again going into clinical practice straight out of work and then direct drifting into these four main pathways over years. And so again highlighting we know that there's a shortage of trained physicians for these demanded jobs out there. So now pipeline issues and again kind of dovetailing from a lot of Saja's talk earlier and I kind of want to just make sure we paint the framework of what's required of these programs really to get the people out there in the community. So it is a very unique training model compared to all other residency programs for a number of different reasons. I mean one we need to have that master's of public health or equivalent type of degree as part of that component of being board eligible for the board certification process. So we've got the graduate degree component. They're all pretty much two-year programs that start at the PGY2 level. There is some nuance and there's a little bit of creativity that we're seeing in some of the residency programs and ACGME allows a little bit of fluidity to what those requirements are but it's pretty much a two-year training model starting at that PGY2 year level. All of the residents coming into the program have to have at least an intern year and then there's a broad spectrum beyond that of what we see from people. I once had a resident who was PGY 13. Many many other residency programs. I had a resident who practiced ENT for 20 years. So we're seeing people come in from one year after medical school and we're seeing people who've been out in the field for ages. And then as Saja mentioned I'll get into a little more details in this too on the funding. So again this is not funded the way all other residency programs. Occupational medicine and general preventive medicine are really the only two main residency programs that require funding outside of the CMS Medicare stream. PEDS is a little bit different too but that they've got nice you know steady funding stream. And this is really important for us as program directors especially because what it means is that we have to spend a lot of our time fighting for dollars to maintain our programs. We don't just get that automatically every year you've got funding for X number of residents kind of coming in. I do want to again to make sure from broad based understanding is the two main organizations that we kind of drive what we do are the ACGME and the ABPM. And I know this is very familiar with many of you but just to be clear ACGME Accreditation Council and Graduate Medical Education basically sets the requirements for the residency programs. The American Board of Preventive Medicine sets the requirements for individuals to become board certified in occupational medicine. So as residency programs we're training the individuals as a program requirements that are met by the ACGME to make sure that our residents graduate and they have all of the criteria that they can actually be eligible for taking the board examination and hopefully pass the board examination. The other kind of really brief thing I want to talk about is there's three different pathways that the ABPM allows. What I'm talking about primarily right now is the residency training model the two-year training model. There's also a small number of people that graduate every year through what's called the complementary pathway and there's just a little bit of different requirements and typically it's only one year of training that's required for those people. They have to have some degree of prior training at least two degrees of two years of prior training on an accredited program as well as completing the Masters of Public Health. And then finally the special pathway. The ABPM sees a lot of people coming in through this pathway. So essentially what that means currently you can take after having completed a residency in any of the three specialties occupational medicine aerospace medicine or general public preventive medicine general preventive medicine public health you can in turn in the next period of seven years at least take qualifications to get another certification. So we see in occupational medicine especially a lot of people who do aerospace medicine will in turn a year later or two years later test for the occupational medicine certification as well. So that's helped spike that number of total people becoming board certified each year. I'm gonna run a little bit quick. I want to leave enough time for talking because one of the main goals of our talk is to actually get some solicit ideas and feedback as well as kind of you know get more people involved in the ambassador program for getting more people involved in the field. So 23 programs the funding sources with this and I have to credit Mike Pratt I'm not sure if he's in the room Mike Pratt at Rutgers and Mike Gottsfeld at Rutgers for the past couple of decades have been serving all the program directors so we can get a real pulse for what's going on within the training programs themselves. So from this last year Mike found that oops excuse me about 39% of residents are funded directly through NIOS that's both through the ERC and the TPG training grants. About 20 to 20% or so in the military programs both in the two military programs as well as several they get funded in civilian programs and they have choices to go at different residency programs in the country. HRSA provides another 10% the VA had most in many institutions provide some training funding for residents and a lot of money comes from home institutions in terms of their GME budgets and then there's a few small grants that get scattered around the country as well so foundations, corporate groups and even there's one that gets labor money. So we talked a little bit about this and this is confusing so many programs have more slots that they've gotten approved by ACGME than they actually have funding for available so there's ACGME approves a total of 187 total slots about 99 slots are funded so there's this gap in funding right there alone of almost 90 residency positions that could be filled if there is funding available for that so much more approved slots than funded slots so that that's one area we could definitely use the money to fill those approved slots and we could actually get more approved slots without too much difficulty I believe from ACGME if we have the program set for them. A big gap right here is the number of medical schools so 23 programs most affiliated with medical schools and there's about 200 different medical schools 190 medical schools in the country with something like you know almost 30,000 graduates each year so we're hitting such a small 50 out of 30,000 medical students each year are finding us and that means that there's a hundred and ninety or so medical schools that really have no academic presence in occupational medicine and many of those have really no affiliation at all so I just mentioned the four versus two hours of occupational medicine training I don't know how that's happening in other schools without an occupational medicine program but this is an area I think we have a huge area where we can maybe intervene and get a lot more word out there from the breadth of our members at least to these medical schools and using local people to get into the schools go to their career fairs get it get involved with lectures and whatnot to help kind of drum up the idea of what we are even this slide came out last year again crediting Mike Mike Pratt and and Bob Harrison just gave a great talk to NIOSH as well a couple of months ago was kind of talking about these same issues Bob Harrison at UCSF but this was really an outstanding fact that came out to me at least and many of us yesterday at our meeting that only six of the current residents in all of the residency programs that are even heard of occupational medicine and medical school now granted they could have been in lectures where it was talked about and they just didn't hear it or they maybe they missed the lecture or whatnot but I mean this is kind of again the kind of penetration of knowledge and medical schools about what we do just where our residents coming from so this is a again much of this next several slides are credited to Dr. Pratt but so again most of the people who have at least of course had that internship about you know 20 of the the current entering class in 23 had two years or more and then about 16 and this is not atypical for most years, had already completed a residency. Typically, family medicine, internal medicine, emergency medicine are kind of the mainstay where people come from prior residencies. Many had experience in occupational medicine and primary care. So about 20 had worked already in occupational medicine and a number of as well in primary care. These are the different types of training programs where we're seeing people coming from. So again, the vast bulk have just done that one year, the internship or transitional year. And I gotta say that many of these people are people that were through the military and had done the flight surgery program or other things and had exposure to occupational medicine through that pathway. So that's where we get a lot of the internship, transitional years, and then family medicine, internal medicine, kind of the bulk of the mainstays, but really from all sorts of areas. And this is another area, avenue, where we have a lot of opportunity to get people in medical schools, at least, is when they, residency programs, when they get into the residency program and find it's really not their fit. This is where we can oftentimes capture people when they learn about us. So I wanna talk a little bit about the training programs themselves too, just briefly. I think I've been in occupational medicine residency training for over 20 years. I've been a program director for, I think, about 17 now. And there aren't that many that have had that many years of experience in our field. I think one of the things, I'm probably stating this a little bit too strongly, but it's difficult for a number of reasons. And there's an awful lot of turnover of program directors, especially in the early years of stages of growth. And so much of that we can attribute to, in the survey at least, the funding certainties for the positions themselves, the ACGME requirements, which are, we're trying to help, ACGME's trying to help make it easier for us. But so about that, of the programs, average median time is about eight years of us program directors. Several have had 20 plus years, but most, maybe many, are in that one to two year turnover cycle. And it's very difficult. There's a long, steep learning curve for all the requirements that we need to produce. So I'm basically putting that out there to hopefully drum up support for these programs, because we need to recruit faculty to these roles, we need to make that an attractive career choice for them, and we really need to kind of buffer the opportunities for losing people at that point too. And from this last survey, I think a couple of quotes that came out that were solicited in the survey I thought were really interesting. One was kind of looking in the top paragraph there, at least, of getting recruitment, the medical students that are out there in the schools that don't really see us. Another person pointed out the great number of people that we see, again, coming through the military, and this is a really important avenue for us to get residents, is people who've had that one year of training and then spent X number of years in the military, often in flight surgery programs, where they really get exposed to occupational medicine, they really come into us with a lot of great experience, and they make for a strong cohort for the most part. But I wanted to read this last paragraph, because I think this is, again, kind of pointing to what I was just talking about a moment ago. The lack of institutional understanding of the complexities of OEM training programs requiring, in my opinion, the writer's opinion, greater administrative support per resident if using numbers of residents as a metric of administrative support than other U.S. residency programs. So again, we have to do an awful lot for a relatively small number of people, so it's very time-intensive, and that, I think, can lead to a lot of challenges for people to stay in that role. The complexity is in part due to the administrative demands of funding in OEMs, such as contributing to NIOSH ERC and TPG grants, in addition to managing rotations and experiences outside of clinical medicine, such as the MPH or corporate medicine, which often are outside of one's institution as well. I don't mean to be this too self-serving, again, I'm at the latter stages of my career, but I want to make sure that we have people that are filling these roles, and support for these people in these roles is really critical. I see as one of the real underpinnings of making sure that we have strong programs, and in turn, bringing more strong residents into the field. Finally, I did reach out to Gail Medlock of Medlock Consulting, and I want to, again, kind of credit Nyla, who many of us knew well and missed quite a bit, but Nyla, a few years ago, before her passing, talked about this, the gray tsunami amongst our field, and again, kind of looked at numbers, how old we are, and stuff like that, but I mean, she really was predicting this, that there's a lot of jobs out there right now for young residents. I think it's a great time to be a young resident, because people are moving on to retirement and whatnot, but companies, they want to fill these roles still. They are looking for part-time residents, is what Gail was telling me. Not as much of the hands-on experience as there was before, because they're basically managing cohorts of either young physicians coming in, or advanced practice clinicians taking on some of those roles, opportunities for independent contractors, and then the increasing role for telemedicine in these roles as well, so kind of a much greater role, I think, from an administrative standpoint for the graying tsunami wave, and then Gail also kind of pointed out that what she's seeing in her companies that they're looking for us is that they didn't really anticipate how important we were with respect to what we were able to do during COVID and keeping people at work, and a lot of companies really see us now as they don't want to be without us, I guess. We need more certified occ health physicians, and they're beginning to try to find other people to fill those roles. There was this caveat that some places that are maybe not as attractive to live, maybe, are more difficult to recruit physicians to, so there are jobs that have sat out there for a long time just because it's difficult to get people to move their families there or whatnot, and then finally, she said the tsunami has arrived, bringing opportunities for OEM physicians in all areas, so there's a lot of opportunities out there for those of us who are graduating, and then just finally, oops, this is what we saw last year for where people went, so most people ended up, if you look at this list, and I know it's really busy, but most people ended up going to clinical medicine. A number, of course, went to the military because that's where they were trained for, and then they'll finish their careers or however much time they have to spend there before they join us in the civilian world, but, and then a smaller number have gone on to corporate medicine and academia. Well, I didn't leave that much time, Saj, for moving on to this, where we really wanted to get into a bit more of a discussion and looking at kind of these ideas to help support pipeline recruitment, especially looking at the DEI issues, and then kind of some of the other ideas that might be out there. Training in place, really, Saj is the leader of that right now, this whole model of how we can get people trained in the community. Many of us are looking at hopefully expanding that as another way to kind of add numbers to the field and looking at different sources of funding for that, but really, you can join me, Saj, or just, I really would love to open it up to get some ideas and maybe some feedback, and I hope we didn't paint too dire of a picture. I mean, I really think there are amazing opportunities for us. We've got a hunger of our residents that are coming into the field. We certainly could use more funding to help support our residents, and I really want to credit Bob Bourgeois for pushing the efforts that he's done the past year and continues to do in terms of looking for legislative funding support, line item support, so. Bob Orford, and past president of ACOM. I trained at the University of Washington back in the 1970s, a long time ago now. I'm from Canada originally, and at the time I was at the U of W, I had my funding from the Canadian government. Just now, before this session, I attended the IOMSC session that was on the other side of the floor here, and they had representatives of many different countries. There are now something like 90 countries in the international occupational medical community of associations, and there's a hunger there among those physicians for training, so I'm wondering whether, as happened with me, if they went to their own governments and sought training, if that would be another avenue for programs in the United States to do what, for quite a number of years in the aerospace world, Wright State did for international federal air surgeons, to bring foreign persons, physicians, into our training scheme, bringing their own money with them. Do you think that would be possible? I can, I've not had that experience in our program, I can say, but I do know, I think, Bob Harrison here, and UCSF, I know, had a program, an exchange program with Saudi Arabia, where they were having a resident per year for a number of years running, so I think those opportunities there, there's logistic challenges in terms of getting non-residents opportunities for training, a J-1 visa type of a program, as happens in other specialties, but I think those logistics can be managed for allowing the training. So the idea being, can we train foreign nationals in our programs as another way to kind of boost the numbers of international grads, I guess? Well, I think there are licensing issues and visa issues, certainly. I don't know how Wright State did it. It might be worthwhile talking to one of the older program directors from that program as to how they brought in international residents into their program. I don't know how they handled the visa issues. Thanks. Thank you, no, that's a great, great, great idea, and somebody's taking notes for, maybe, thank you so much for your presentation. My name is Sonny Onyabu. I work at Gunderson Health System in La Crosse, Wisconsin, and I'm associate professor for UW Madison, Public School of Medicine and Public Health. So as part of what I do is to kind of integrate occupational health into family medicine residency, rural family medicine residency program. So I get to teach them, go to their seminars, they come to our clinic to learn, because they know they're gonna participate in rural areas. So my question is, is there any way we can get to partner, have a combined residency where a family medicine resident gets to finish up a program and having both family medicine and occupational medicine while they are residents? Because they understand that when they're in a rural area, they have all these opportunities, and they want to learn the skill, but once they leave the program, the family medicine program, it's hard to come back to say you want to do a new residency. But if there's a way to maybe four years of a dual residency, and in situations where you have both family medicine and board certified occupational medicine physicians who are faculty members, that could be a way to improve our odds in the future. So I absolutely agree with you, and frankly, I'm gonna go ahead and call you out, Bob, because one of our graduates, Bob Chestnut, did exactly that, and there is a pathway for that. You can do a combined residency program, and ACGME allows us to actually have kind of sharing some of the training that you get in family medicine, internal medicine, to be board certified within a four year period of time. And I think Bob is really the poster child for my program, at least, that has done that. Miss Brent's here, too. But there's definitely an avenue that we can pursue, and I think Saja's program with the training in place model really epitomizes that. Two comments, I'm a prior residency director for four and a half years in Minnesota, but one of the unspoken elements in the room is that the vast majority of providers or doctors doing Occ Med are not boarded. I think the majority of people even in AECOM are not boarded. One of the things that was not broken down when you talk about boarding is what percentage of people that were boarded were actually residency trained. That's not been broken out. And this goes back to, it changed in 1985. If you were graduated before med school in 1985, all you need to do is two years of practice in Occ Med, then you can sit for boards. I took the boards, I graduated in 86, so anyways, I had to take a residency. When I took the boards in 92, over 400 people took the boards because most of those had sort of grandfathered in on that. Now they're less than 100, so that's something that has to be looked at. You really need to break down the number of board, the number that are residency trained, and that's something to look at. The second comment is when I was residency director, our recruitment strategy before I got there was to wait till March when people didn't match. Everybody would call and say, I've got to do something, I've got to do something, and we tried to do that. I basically told them we could not do this, we were a not-for-profit, I said I cannot run this residency unless we get dynamic med students, and they allowed me to take one PGY1 position in a very prestigious transitional program. I said I cannot make this work. We selected a dynamic PGY1 in a transitional program that had been radiology and dermatology and anesthesiologists. He became the chief resident, and we ended up recruiting after that other people in anesthesia. Two from there, they stopped letting us near the anesthesia residents because they found out about med, we recruited somebody from surgery, from family practice, but it's my own personal opinion that until we get PGY1s, we are not going to be able to recruit dynamic med students because you're gonna tell them, go find a transitional, something very hard to get into, do family practice, and drop out. So that's something you need to look at, is being able to recruit dynamic PGY1s, and then you can talk to med students to say there is a path for you to get into this specialty. Yeah, no, thank you, and John, I just want to point out, yesterday we had a, Dr. Sharip at Loma Linda told us that they've started that at their program, and they've now got, I think he said they didn't even enter the match because they had four people that matched to their program in the PGY1 year. We don't have the match anymore because so many people know about it as med students and residents. Hi, just kind of a comment slash question, but I'm in corporate medicine working for a company, and one of the things that I fell into this role after many years of practicing clinical medicine, I was not board certified in occupational health, but when I look back and I hear your presentation, one of the things that stick out to me is that the occupations, the workforce has changed over those years you described, right, from where you have certain sectors where the occupational risks are still present, which is what you study for, like military, agriculture, energy, oil, correct? But there is such a large boom of knowledge workers now where the occupational hazards have changed from physical ailments to now mental ailments, and private corporations are now seeing this need and a desire for OCMED in the realm of how to manage their workforce to improve productivity, reduce absenteeism, presenteeism, goes away from the physical component more to the mental component, and looking at programs to support the health and well-being and productivity of the entire workforce and not necessarily keeping them physically healthy from environmental or occupational hazards. And so when you think about that pipeline, there needs to be some form of a partnership or training with private corporations, but being on this side of the fence, I would tell you it's very challenging because a lot of private corporations do not want to share their personal employee data with any other organization, let alone anyone outside of the organization. So my question and challenge back to this group is how do you create that type of a pipeline where there is a need, but there is no desire to share that kind of really personal data? I'll let you take that one, Sash. Well, right, I mean, it's a good thought, and yes, we don't have that information. The other thing is on similar lines you mentioned like corporations and private industry, the fund that I showed that's obsolete now, that was actually created by some of the major corporations, lasted for maybe one to two years, but then that was set more for corporate medicine like physicians, but that sort of died down. I guess that sector, and then it just, the whole funding died down. So yeah, it's a good way to re-approach. Maybe one more question. I'm sorry, I know we're into the break time, so anybody's free to leave, but before you leave, myself, on behalf of Dr. Wood, thank you very much for your highly interactive session here and thank you, Mazal, for moderating. So last question, maybe. I'm Chip Carson from Cincinnati. I'm one of the 20-year program directors that was on the slide earlier. I was at the University of Texas for a long time. I feel need to talk about a couple of the previous comments. First, regarding the dual program, we ran an occupational medicine, internal medicine joint program for a dozen years, and during that time, we had many applicants, but we only had put one resident through that double program, and that's owing to the collaboration between the internal medicine program and the occupational medicine program, which was very administratively difficult, and there were conceptual issues that influenced that. The second comment is regarding the, let me see, what were we talking about? Well, I need to speak to the source of funding. One of the things that we had success in in Texas during the 20-teens was implementation of a clinical service within a teaching hospital. We were at an ERC in Houston. We had a big medical center there and several large teaching hospitals, and we were able to establish a clinical service which funded one residency position in our program for a period of time, so that's something that is a possibility, and if anyone's interested in talking about how we did that, I'd be happy to do that. Thank you for a great presentation. Thank you, thank you. We are making some notes, and we're more than likely, I will be approaching you, I will. And Saj is the chair of our group next year. He'll be able to champion this stuff with our support. Thanks, and I would like to recognize Matt Hamm. He's sitting in the audience. He's a resident up in Boston, and he presented a very nice presentation yesterday to the program director's meeting yesterday about some ideas on how to reach out to new applicants and develop new interest, so. Thanks, Dr. Sewell. Maybe like a 30-second quick. Yeah, and Kenji Sato actually is, as part of his incoming administration, is trying to identify a few things that are really high yield for us as an entire specialty, and the pipeline is frankly a top priority for the entire specialty, and so he's got a presidential task force. We need a lot of volunteers and a whole lot of ideas. If you're interested in volunteering, the pay is about zero, but you get to work with cool folks and solve this huge problem, let me know. We'll get you in touch, and we're gonna kick that off here in the next few months. Thank you. Tackling all these big issues. Thank you. Thank you. Thank you. Thank you, Tom.

occupational and environmental medicine

training programs

physician shortages

training and certification

centers of excellence

integrating environmental medicine

funding for training programs

practicing occupational medicine physicians

recruiting international physicians

combined residency programs