Well, thank you for your patience, and also thank you for sticking around. I think this is the very last talk. And so our title is Challenges and Best Practices in Non-Traditional Occupational Health Settings. You're probably wondering what that means, and we'll talk to you about what that means. I am Cheryl Bednow, and I am the Occupational Health Advisor at the U.S. Department of State. And I'm joined here by Dr. Pete Matos, and he'll introduce himself shortly. And we're kind of giving our talks very separately because I'm part of the federal government and he is not, so we kind of have to keep things a little bit separately. So if you're wondering why things are a little bit fragmented. So my role is a little bit unique. I am the only one or the only one that I know of that is Occupational Health Physician or Occupational Medicine Physician at the U.S. Department of State among a group of health professionals that do occupational health. And I'll talk to you a little bit about what that's like to work among a large group of providers who do services around the world. I'm going to proceed because I'm going to get us out on time. So I have no disclosures, and I think Dr. Matos is going to say the same. He has no disclosures. Planning objectives, I'm not going to go through them. You can read these on your own at a later point. So the agenda, I'm going to cover the first few. We'll probably take a really brief break in the middle and have a brief discussion. We'll see with kind of the adjusted time. And then Dr. Matos will take the later part, and then we'll have some discussion at the end. So why are we doing this presentation? Dr. Matos and I both did our training in the military, and then I spent most of my 20 years in the military. And I think my training was very, probably very policy-driven. Everything had clear guidance. And then I end up in a job where it's not well-defined, and occupational health is mostly done by people who don't do occupational health, do not have the training, and there's no clear framework. And I find that after you leave a very well-defined setting, and it's not just my current job, but I've talked to many people who don't have very clear guidance and a framework, and they're working in other settings. How do you kind of work in such a setting that isn't so well-defined? So we're going to kind of talk about a couple of examples and how to deal with that. So what is a nontraditional setting? It's not an official term, and so for the purposes of this presentation, it's a setting outside a well-established structure. So outside of traditional academia, hospital industry, or very, or strictly defined occupational health clinics. But I really see this on a continuum. There could be really well-defined or somewhere in the middle, or it could be a setting that is under-resourced. And so what are the potential gaps of a nontraditional occupational health setting? Lack of occupational health experience. As you all know, there's not enough board-certified or trained occupational medicine physicians to go around. There isn't leadership buy-in or knowledge about what we do or what occupational medicine or what public health does. And there's no specific EMR or record-keeping system, and there's just not enough resources devoted to occupational health. So now I'm just going to go into what we do at the U.S. Department of State. And I'm using kind of occupational health on a broader sense, and then when I talk about occupational medicine, more on the medicine type. But U.S. Department of State uses occupational health for both. So sometimes I may use it for both purposes. Most of the occupational health services at the Department of State are done by primary care providers. Those are either physicians or mid-level providers, and those are at the health clinics, health units or clinics throughout the world, and I'll talk to you about that in the next slide. And often those services need to incorporate local laws or labor laws. And there is, to my knowledge, although there could be others that I don't know of, one federal certified occupational medicine physician, that is myself, based in Washington, D.C., although some of those other clinicians may have past or local country occupational health experience. So what is a little bit more about the U.S. Department of State? The U.S. Executive Department of the U.S. federal government, primarily responsible for U.S. foreign relations and policy, maintains approximately 273 posts around the world, so your consulates, embassies, et cetera, who are the employees, foreign service officers, civil service, and I'm a civil service employee, contractors, locally employed staff, and that makes up the bulk of the employees, eligible family members, and others. And I think that complexity of the type of employees makes things very challenging for occupational health. So in terms of the medical assets, all of them fall under what's called the Bureau of Medical Services, and the frontline clinicians are either medical officers or medical providers. The medical officers are, that's another term for the physicians, and they're mostly family medicine trained, although some are internal medicine or emergency medicine, but they have to be primary care. Or medical providers, and those are nurse practitioners or physician assistants. And you can see kind of the regional distribution of those medical officers and medical providers, plus other medical assets such as nurses, front desk support, et cetera, at each of those. Plus the workforce is augmented by locally employed physicians and nurses from the countries of where those clinics are. Plus there are medical officers and providers in Washington, D.C. who provide expertise and support to those in the field, like myself. So just a little interim discussion here. So those clinicians at those health units or those clinics at those 273 posts around the world are expected to perform employment-related evaluations and reviews. What issues or gaps would you anticipate if you have primary care providers do occupational health exams? These are people who are put in those roles because they have strong primary care skills, and they do occupational health. Do you think that there's any challenges there? Anybody? We can talk about that at the end, but yeah, there are some real challenges there. And so that is, it's very difficult to teach people, especially from D.C., how to do occupational health, especially in over 250 places around the world, with local differences. It's very hard. So a big thing that you can imagine is training and education and how to keep up with the turnover. And I think this applies anywhere, and I mean, my example is probably rather extreme, but wherever I've been in different settings, teaching people, because as I mentioned earlier, many people who are serving in occupational health roles may not have the training in occupational health or occupational medicine. So as I mentioned, these are primary care-focused individuals who are doing that, and they often have to switch. So sometimes the exams they're doing are for the same employees they're taking care of on the primary care side, so the things get intermingled, which you can imagine can be even more difficult. And so what do you think happens is sometimes you do unnecessary questions and tests, let's do more labs, which on the occupational health side, let's not do all those extra labs and all that extra follow-up, that's way over. So the best practice is just regular training on what is occupational health and creating some templates to follow. So I did a series of training for the primary care providers last month, and they had never gotten any training, and some of them even said, we tried to find short modules. And they looked up, and they couldn't find anything that was really good. And I looked myself. I found some outdated stuff, but I was trying to find some good resources that were already done on just occupational health for primary care providers. But they didn't realize that there were such differences between primary care and occupational health. And so we talked about just some basic concepts and kept it really simple, but some of what I taught them, I think, could apply beyond them. And then leadership buy-in. I think my experience over the years, just as a public health person in occupational health, leaders don't really often know what we do, and it has often come from the top of explaining that. And so even in my role explaining the importance of a strong occupational health program over and over again, not just once, but regular engagements on the importance. And they're like, well, isn't that what safety does? I'm like, we're a little different than safety. We're not the safety in occupational health, they think. We're the same thing. I'm like, no, we're different. And so I think there's often confusion on terminology. So again, leadership buy-in. So I'm just going to give an example before I move on to the last topic and transition to Dr. Matos. So an example of where things get very challenging on a global basis as a program, like hearing conservation and audiometric testing. So if you think about testing those who are noise exposed and need to get regular hearing tests, how would you do that around the world? So I had to think through a solution. Would we do that at every health unit? Would we train people on doing that? Would we have people go into booths? Would we do booth-less testing? Would we send people to a location on the economy? Does every place around the world have those resources? Do we have people go to regions where they have them? So that's one of the scenarios that we have to face with employees around the world who do have needs for such testing, as well as how to track that information in a way where we can capture it, because these are employees who move often. And so how do we capture it in a way that if they get it in one location and then the next year they're in another location? So these are things that we have to come up with. And a lot of occupational health practices are paper-based. And this is an area where we just can't be paper-based because of the mobile nature of this workforce. So this is just an example of where there's really not an easy answer and no solution is really perfect. And I'd be interested at the end to hear what you think would be the best solution of doing audiometric testing in such a population. You might have a better answer than I came up with. So here I'm going to transition to Dr. Matos. As I mentioned in that last slide, recordkeeping and electronic health records, not easy. And if anybody has a solution that is perfect for occupational health, I'd love to hear it. It's especially for a workforce that is mobile like ours, it's very important in maintaining longitudinal records, but also keeping separate systems between primary care and occupational health, very important. But I'm going to transition here to Dr. Matos. Thank you, Cheryl. I've got no disclosures and I know time is short so I'll try to speed things up. When I was in the military for about eight years, I worked with the OCMED consultant trying to evaluate occupational medicine EMRs. We never found a great solution. So one of the things we encounter in the military is someone comes to your clinic, I'm an active duty military officer, they're now out of the military and they're applying for a job and I'm going to look at their medical record, which is their military medical record, but I've asked no permission from them. So one of the things that we learned from our mentor, Dr. Richard Thomas, at the then Bethesda Navy Hospital, now Walter Reed Army Medical Center, is that we would ask verbal permission and we would actually have them sign something. And so that actually still goes on today. I'm now a consultant for a government contractor and we have a similar issue and I implemented the same strategy there, right? Just because you can doesn't mean you should because the records are separate, whether it's EPIC or Cerner. And kind of a real world example is I do a lot of wellness and fitness for police departments and firefighters and I end up getting that business because the unions get upset because the firefighter goes to say their family physician who accesses their personal records and fills out a form for employment when they never ask permission to look at those records. And so what ends up happening is we end up going low tech. So they end up going outside of the health system to myself and a partner that I work with, a physical therapy company, and we maintain paper records. It's not a perfect solution, but it makes sure that the records are separate. So I think that problem still persists today and I think it's a challenge with no perfect solution. So the other thing is recording things when you have no EMR, when you're consulting. So I do a lot of work. One of my partners is ISOS and corporate medical advisors and I have a diverse client base. So one of the things is you get calls for emergencies. They're not necessarily medical emergencies, but let's say there's an exposure or there's something else that happened, that data will come to me via text or a phone call. And as you know, any good lawyer from med school taught us all, if you didn't document it, it didn't happen. So what I try to do is take whatever's in those texts or whatever I received in a phone call and then follow up with an email to the individual, to the different stakeholders. So I think it's not an EMR, but you're doing some type of medical consulting and that information needs to be captured. So kind of keep it simple. And I think putting that information in an email is a good way to go about that. The other one is policy on the fly. So you know think of Cove it right. You have this emergency. People are trying to come up with policies. The other areas as Cheryl said the military trained us really well. Well we always have a plan. So some issues you know happened in Ukraine. Everybody was trying to get potassium iodine tablets. OK what's your policy going to be for people that are in country in Ukraine. What does that look like. Why do you do. Why do you do what you do. I had one company that wanted to get gas mask for all family members. What does that look like. And does that actually really make sense. And what do we know about that. So the other piece too is making sure all your stakeholders are present when you have an emergency. So generally that's H.R. legal safety operations and security making sure that you've got everybody that you need at the table at the time of the event. Trying to think I had another recent one where they thought they had an exposure with radiation exposure. Same thing. They didn't have legal on board and they wanted to move forward. I gave them advice but they had to get their legal on board. So I think it's it's making sure that all the stakeholders are at the table and that you're able to communicate clearly. So I know time short so I'd rather open up the floor to discussion. Do you want to. Yeah. Yeah. And I think the best part of these conferences is kind of getting input from each other on some of these topics. So in I'd be curious from some of you about how you if you've had experiences educating or working with primary care providers. We'll start with that topic. If you come to the mic as well probably like a lot of people we've taught rotations which is usually like a day for family medicine residents in a semi academic or academic setting. And they're terrified of workers comp forms. They don't know anything about this paperwork. They don't understand the system. They don't understand causation. And you try and fill it in really quickly in like one day or sometimes just part of a day. And that's my experience with working with them has been residents right. And I think that's the challenge is they may get it really briefly during residency. And that's what they tell me is that oh yeah I had it briefly during residency and I remember the workers comp stuff and then I don't remember anything else. And I think that's the challenge is that they don't really understand it beyond a really brief experience. Thank you. The experience that I've had has been. What do you do. Like you know like almost like what do you do. What does your specialty mean. And at times not many times but there have been times where they're like well you know almost like not giving as much value as what it is. And at and saying you know just. So I think that overcoming that barrier in some cases is half the battle. And then once you see I think with Covid now people see you know what's the value of it. But there are times that people like what I don't really understand what you do. It's just these documents. I could do this kind of things when in fact many times people come and see us after they've seen their primary care because there's lack of clarity of the work restrictions and the details associated with our specialty. Yeah I mean I think that's a really important thing is educating people about what we do and the importance of it. So great point. Hi. I worked for the V.A. for 20 years and you will find in the V.A. that the occupational health providers mostly have less than two years of experience. So what you're getting at does not just happen in these non-traditional settings. So we had a national education team. We put together a guidebook that people could refer to. We had a occupational environmental health consult team where they could get real time advice. We've also I'm a member of the nurse practitioner section and we have gotten a lot of feedback from the physicians that they get nurse practitioners on board and they have no idea what they're doing in occupational health. So just so you know we put together a year long training program. It's a cooperation between ACOM and AANP and it's being taught by both nurse practitioners and physicians and it is available online if they can't make the actual scheduled presentation. So that might be helpful to you. Yeah I think that new nurse practitioner training I mentioned it at the at the education session I did last month because it was right in the middle of my my series of talks I was like update. So it was good timing. I think people are interested to hear when they find out more about it. I think they they're like oh there's that's really an interesting field. But I also found in teaching it that there's a little bit of backlash that they're like well all those testing that I'm doing on my patients you're telling me I can't do it anymore. And they said well isn't that a great service to my patient. I said well that's not exactly what we're doing. We're not providing all these extra labs and then they're not. It takes a while to explain why we're doing these exams. And I think most people get it but some people it takes a little bit longer than others. But I think it's now we're changing it that a lot of this education we're going to start to provide when these providers come on board and then on a regular basis because I think if we don't provide it from the start as well as continuously then it's going to cause a little bit more work and extra labs and additional costs as well. I also agree with you the point that even in these well established settings in the federal government it's not perfect. My name is Donna Bates. Can you hear me. I'm sorry. Yes. I'm a recently retired medical director for solar turbines which is a company that has employees in 125 countries different languages etc. I can speak to the third bullet. Oh yeah. Go ahead. Yeah. Testing in a global environment. That is probably successful expertise. We utilize actually the chaotic occupational nurses who travel to in our organization. We have somebody has an annual meeting every year and in that annual meeting it's in a hotel like this. We convert two suites. We do offshore exams. We do audiometric testing respiratory testing for all of the employees who come to that regular meeting because they have to have regular annual follow up. So we travel to Dubai Singapore Kuala Lumpur Australia wherever they have the meetings Australia Argentina. You name the country we simply go in. It takes a certain amount of time for each audiogram. We capture that data on all these sophisticated equipments that we have here with exhibitors. It downloads into the system does the STS automatically and it talks to the computer back in our home office. So we accomplish that. And of course the staff enjoys the travel as well. But that is our expertise is going all over the world doing health surveillance. Well that's great. Very good. Yeah. Thank you. Anybody else have. Go ahead. Yes. Chris I'm actually a former army flight surgeon. So we did something similar. I had an issue with trying to get audiograms. We worked in military intelligence so we had teams deployed all over the world. And so when we had to get a team I actually trained my medics my 68 whiskeys to be CAOC certified audiology techs. So we all went to the training together and then we purchased one of the vendors here a boothless audiogram and we were able to travel with that. So it's just basically a suitcase and he would travel. And what we actually found out it was actually very useful even for people local who would somehow always find an excuse not to go get their audiogram. I was then able to make basically a program for my medics to go hunt them down kind of like a bounty hunter system to find those individuals and then out in the spot give them an audiogram. So it was kind of a nice tool to be utilized even in a resource plussed up area where you can get an audiogram. Yeah. No thank you. And what we're looking at now is is one of the boothless systems just because I think the at least having the booth based testing is difficult because you have to have the CAOC certified technician and it's just it's a huge expense to maintain especially with people the turnover and the additional expense. So I work for a global mining company in six territories. So we face so the electronic health record for instance you're so what we've elected to do is to get one vendor out. We don't think there's any one that is superior to any of the others. All of them need work. All of them need but to have one for your company you know or your organization that is the architecture starts at the group and looks after all of your divisions and so on. So we're in the process of building that and building standardization across the electronic health record irrespective of which territory. I think it's the same point with. So what is the real difference between primary care and occupational health. You know it's just it's a it's an idea or you know it's people understanding. When we were taught you know you were taught to ask what work a person does you know and then from that you know so and then you need primary care. Most of the information that you need is actually can be collected by anybody. They don't need to have any occupy. The thinking takes place in the background and in the workplace actually. The second thing is what your metric testing we think is is something tele tele audiometry. Probably you could have one center in one place and do audiometry across the world with the right kind of infrastructure. It's one test that can be that suitable to to to to a technological solution where without having people you just need the end user equipment that anybody can put on. You can do it on a cell phone nowadays. It's that it's that advanced. And then the issue is at a data level. You know the difference in countries is not it's what frequencies are used to measure what. It's not and at what level. So that's how you calculate. OSHA has got one. South Africa's got this. Brazil all using the same basic data set but weighting different things on it. And that so I think the solution is in in the data manipulation. So you can get an OSHA report out of that. You can get what the Brazilian government wants out of their report and so on for the same set because it's just frequencies and decibels that differ amongst countries. And I think a similar thing happens in all standards whatever they may be. You know each country selects what they think is important and you need a data solution in the background to to to do that. So that's where we thinking. Yeah I mean and I think it's along the lines of what we looked for is having this equipment at the different places but having the technology centralized and if we needed to translate any of the the differences locally we could program that in through the technology. And so that's what we ended up at least. That is our plan that we're starting to pilot actually this week. Thanks. I'm Rodolfo from Guatemala. One of the things that I would suggest in terms of training because you refer to non occupational medical doctors and because you are basically set around the world I saw a lot of regions you should contact or you could contact the local medical societies of occupational medicine as a member of the international component or ICA. I come say we could for example help with that because some of these societies already have good platforms in terms of training. So in terms of training locally with the regulations as Elton was mentioning for example the difference between South Africa or Russia for example. So that could be a potential good solution for your team as well. I have an example and I have I'm not selling anything but in my country for example we do have almost 75 presentations recorded and uploaded into a core system so it is a self paced course in the web obviously in Spanish right now but things like that are already available in the rest of the world. So maybe a more in-depth conversation with the component will be a good idea for you. That's excellent. I'll actually look into that. I mean I think some of that stuff is really helpful. And just by talking to the field some countries have really well developed occupational health systems. I've been really amazed just by talking to some of the U.S. trained providers. Just I mean they rave about how good some of the countries are in terms of occupational health. So I definitely would be interested in that. I mean I think in my position it has been eye opening on the training primary care providers about how little they do know but also how much some of the other countries do know. I just want to make a comment that the OSHA age correction misses up to 36 percent of actual hearing loss since a lot of times SDS is sometimes hearing loss is often imperceivable and by the time it is it becomes irreversible. And so when to start creating like an international platform you have to ask yourself about the sensitivity of these tests especially if you're like doing on the phone. Someone mentioned and so NIOSH does better in terms of detecting imperceivable hearing loss. And so I guess you would have to consider the sensitivity of the screening test too if you're using like different type of technologies. OK. Great. Thank you for that. Any other comments. Anything. I think lots of great ideas. I mean the talk was a little bit of a mishmash but I think. Go ahead. This is really more of a question for you. How do you set the medical employment standards for your American employees who range from drivers to secretaries to Foreign Service people. How do you. Where do you set those standards in terms of. So it's just for like a pre. Well about pre employment but pre deployment. Maybe that's the right word. How do you decide there. How do you set the floor of health to be assigned to go somewhere for various employees. So interestingly for my job I have no purview over the Foreign Service officers. Most of my work is for the support overseas Foreign Service officers are kind of a separate section and their exams are done separately. It's sort of an interesting setup. It's it's a little bit. It's somewhat I guess it's a little different but just having been in the military kind of the civilians in the military separation Foreign Service are kind of like the active duty. They come in separately and they're handled separately and we're doing sort of civilians. But a lot of what I'm doing is trying to figure all this out. There hadn't been anybody in my role for many years and just trying to figure out the gaps. But that's I mean it's a great question. But some of these things are to be determined especially as far as civilians overseas the locally employed civilian staff and those standards. Yeah. You would have to meet for a local employee you'd have to meet local standards for an American employee. I assume you'd have to meet U.S. standards of whatever both standards. Yes. Yeah. I mean and a lot of that is some local law is very tight and some of it doesn't. It's not. And so it's just mirroring up what is U.S. look like. And some of that is really on the local folks to help determine it's not going to be. Well we'll worry about the U.S. then it will go to the individual countries. But you can imagine it's it's it's very challenging. Yeah. But any other. But lots of things to think about. You gave me ideas too. So I appreciate it. Good dialogue and hope your hearing recovers from that testing. And thank you for your patience today. Hope you have safe travels home. But thank you again. Thank you. Thank you everybody.

Non-Traditional Occupational Health Settings

Challenges

Limited Resources

Training

Electronic Health Records

Stakeholder Involvement

Audiometric Testing