Topic 6: Healthcare: Organization and health human resources
The healthcare system is critical to the worker’s journey. While the MLITSD has direct involvement in the OHS system and the WSIB interacts with the healthcare system once a worker has a claim, they have little direct involvement in the HC system generally. Further, healthcare providers have generally had little involvement in the OHS system, particularly at the system level.
The HC system is complex, under tremendous pressure and transitioning to new models of organization and delivery of care. Care is provided to workers by many components of the HC system, including primary care and walk-in clinics, emergency departments, specialists and in hospitals and other healthcare institutions.
There are many healthcare professionals who may be involved in a worker’s care. In the case of occupational disease, physicians are generally the key healthcare provider that will make the diagnosis and provide treatment. Throughout this chapter, we will generally focus on physicians (as they are the key focus of several of these topics) but note that other healthcare professionals are involved.
This review covers several topics related to the healthcare system. While there are specific recommendations/solutions for each, there are several overarching ones that are fundamental for all.
Ontario legislative and regulatory requirements
There are few legislative and regulatory requirements for healthcare providers under the Occupational Health and Safety Act. The main ones relate to the designated substance regulation, as noted in Chapter 2. The only reporting requirement related to these medical codes for DS is if a worker is found to be unfit or fit with limitations. The requirements under the Workplace Safety and Insurance Act are for healthcare providers to provide the WSIB related to a worker’s claim.
Before the current Occupational Health and Safety Act was established in 1978, there was a unit within the Ministry of Health for the medical aspects of occupational diseases. This was moved to the Ministry of Labour to consolidate expertise in one ministry.
Historically, there were a number of physicians who provided services to industry, usually either large corporations and particularly those in isolated areas such as mining. As occupational medicine was recognized as a specialty in other jurisdictions, these occupational physicians advocated to the Royal College for the recognition of occupational medicine as a specialty. In 1985 Occupational Medicine was recognized by the Royal College, and the first examinations were held in 1988. Even those who had been in practice had to sit the examinations to become recognized specialists.
The University of Toronto had a long-time interest in occupational medicine (initially called industrial medicine) and offered a Diploma in Industrial Medicine since the 1940s. In the 1970s, the Ministry of Labour supported occupational health activities at several universities in Ontario. This included Manpower Training Grants to McMaster University and University of Toronto and smaller funding to several other universities for resource centres. This funding supported the Occupational and Environmental Health program at the University of Toronto that provided education for physicians and occupational hygienists through a Master of Health Sciences degree. McMaster instituted a Diploma program that included different disciplines working in occupational health. This funding supported the two full-time occupational medicine specialists sited at St Michael’s Hospital.
With the recognition of the specialty University of Toronto created the Division of Occupational Medicine within the Department of Medicine. This provided the academic home for the occupational medicine training program, which enrolled its first trainees in the 1990s. The funding supporting the Manpower Training Grant was eventually withdrawn by the WSIB. The University of Toronto continued to support the occupational medicine physicians, which allowed for the continuation of the educational and research programs in addition to clinical services at St Michael’s Hospital. However, this support ended with the retirement of these two occupational medicine specialists.
At the same time, the Ministry of Labour provided a one-time grant to St Michael’s Hospital to establish an occupational health clinic. This led to the creation of the Department of Occupational Health at St Michael’s Hospital. The clinic was eventually staffed by two full-time occupational medicine specialists who not only did clinical work but also set up and ran the residency program and started a program of clinical research focused on occupational dermatitis, occupational asthma and hand-arm vibration syndrome.
In 2004 the WSIB funded the Occupational Disease Specialty Clinic at St Michael’s Hospital.
The program has four streams of focus: occupational skin disease, occupational lung disease and allergy, hand-arm vibration syndrome and general, occupational medicine.
The occupational medicine specialist group in Ontario is composed of a relatively large proportion who were credentialed when the specialty started, and this group is now reaching retirement age. In Ontario, there are 30 occupational medicine specialists. Five are formally retired, and another 11 are retired or close to retirement. The remaining 14 practice in a variety of settings, including the MLITSD, WSIB and industry. Other physicians who practice occupational medicine are credentialed by the Canadian Board of Occupational Medicine. This does not provide specialist status and in particular for occupational disease, lacks any requirement for clinical expertise beyond that of a primary care physician. Some physicians may also practice occupational medicine with no occupational medicine credentials. The Ontario Medical Association has a section on Occupational and Environmental Health. It has 111 primary members and 264 who have primary membership in another section (for example, family practice) but also indicates an interest in occupational and environmental health.
Clinical service – occupational medicine
The Division of Occupational Medicine at St Michael’s Hospital is the only formal clinical site that provides specialist clinical services related to occupational disease. This includes the WSIB OD Specialty Program and referral clinics focused on contact dermatitis and general, occupational medicine. There is one formally retired but still essentially full-time occupational medicine specialist. There are two part-time occupational medicine specialists who spend the majority of their time in other organizations. In addition, there are three dermatologists, two respirologists and one allergy/clinical immunology specialist who all have expertise in the occupational disease relevant to their specialty. The retirement of the two full-time occupational medicine specialists has created gaps not only in clinical care but also impacted the educational and research activities of the academic occupational medicine group.
There are currently three universities in Canada that provide specialty training in Occupational Medicine: the University of Toronto, The University of Alberta and the University of Montreal. These programs generally admit one resident per year.
There continues to be a clinical research program primarily focused on contact dermatitis and hand-arm vibration syndrome. However without the two full-time occupational medicine physicians it is challenging to maintain its previous level of activity.
There are pockets of clinical research in other centres, notably dermatology in Ottawa and respirology in Kingston.
Consultation and review summary
Reports and reviews
There are no reports related directly to healthcare activities related to the OHS system. While a number of reports on other topics make recommendations related to better physician education on occupational topics and the capture of occupational information in the (electronic) medical records they have not studied these issues in depth.
Stakeholder focus groups
- Need to increase healthcare capacity.
- Need for clarity and protection of worker rights to protect their health.
- Clarify and simplify the worker health journey.
- Clarify roles at each step of the pathway.
- Address the potential for conflict of interest for physicians to ensure they are not caught between advocating for the health of a worker and protecting the employer.
- Create some level of independence.
- Need transparent collection (why, what, how) of personal and workplace health data.
- Improve reporting of occupational diseases — what, how and to whom — to support making the link back to prevention.
Summary review findings
- While the OHS system is dependent on the healthcare system to deliver care to injured or ill workers, there has been little attention paid to the relationships between the two systems.
- While Ontario has had a strong academic, occupational medicine presence providing clinical care, education and research, this is in some jeopardy with the retirement of the two full-time occupational medicine physicians.
- The OHS system has expectations about primary care physicians and their practice related to OD. However, with the current state of the healthcare system, including primary care, relationships and expectations need to be built with sensitivity and respect.
- Specialist physicians (for example, respirology, dermatology) in the Province are seeing patients with occupational disease, but they are not formally linked to the occupational medicine specialists or provincial case data.
- There are a number of physicians who practice occupational medicine. They may work for service providers (companies who provide occupational health services to industry) or contract directly with industry. Little is formally known about their qualifications, and practice and stakeholders have raised concerns regarding trust.
- While the review has focused on physicians, consideration of other health disciplines, particularly occupational health nurses who work primarily in industry is needed.
- Clinical capacity improved.
- Primary care is enabled to provide appropriate care for those with OD.
- Other health disciplines, particularly nurses, are well integrated to care pathways.
Short term recommendations
- 6.1 Recognize and resource the Occupational Medicine Clinic as the provincial academic OD hub (clinical, education, research) for occupational medicine specialists and the networks of specialists and primary care providers working in occupational medicine.
- 6.2 Establish a network of specialist physicians and nurse practitioners for patient referrals from medical screening programs, to provide clinical care for workers with OD across the Province and to participate in acute and long-latency cluster clinical response teams where the key issue is diagnosis.
- 6.3 Create a primary care “incubator” with a large academic Family Health Team to identify helpful and feasible ways to improve primary care involvement in the occupational health response in Ontario. Through the incubator, understand the clinical training of family medicine physicians related to occupational health and disease.
Longer term recommendations
- 6.4 Continue to develop the occupational medicine (OM) academic hub and regional specialist networks, adding additional specialties as needed.
- 6.5 With an understanding of the landscape of primary care, consider a pilot of a OHS navigator embedded in a FHT to support occupational healthcare; consider a potential role on the Ontario Health Teams.
- 6.6 Consider the roles of other health professions specifically related to occupational health to continue to build capacity.