ACOEM: MDs must supervise TB surveillance
June 1, 1998 8 minutes read
ACOEM: MDs must supervise TB surveillance
Doctors' group challenges proposed TB standard
Concerned about language in the proposed tuberculosis standard1 that would allow medical surveillance of health care workers to be performed by licensed health care professionals other than physicians, the American College of Occupational and Environmental Medicine (ACOEM) has accused the U.S. Occupational Safety and Health Administration (OSHA) of failing to protect workers by not requiring physician supervision of surveillance activities.
In both a prepared statement and in testimony at recent OSHA public hearings on the TB proposal, ACOEM criticizes the agency for developing standards that allow worker health to be monitored without physician involvement, even when the non-physician health care professionals providing those services are operating within their licensed scope of practice.
ACOEM, a 7,000-physician medical specialty society based in Arlington Heights, IL, apparently has declared war on all OSHA standards that include the wording "other licensed health care professionals" (LHCPs) in provisions describing who is permitted to perform medical evaluations and procedures, as well as medical management and follow-up, for workers in occupational health settings.
The organization has filed suit against OSHA for similar wording in the recently finalized respiratory protection standard, after an unsuccessful attempt to sue over the same issue in the 1997 methylene chloride standard.
ACOEM cites lack of 'requisite competencies'
In a prepared statement relating to the proposed TB standard, ACOEM maintains that "a medical surveillance program will require physician involvement and the standard should make that clear. . . . [T]his standard poses the potential for an employer to rely on a health care professional who lacks the requisite competencies and training to make the necessary medical decisions with respect to an employee's health and the effects of a tuberculosis exposure."
ACOEM further charges OSHA with creating a "dilemma . . . between ensuring that an individual can practice within the scope of their license and ensuring the health of a worker." The TB proposal puts employers in "a gatekeeper role" that denies workers access to medical doctors and potentially threatens their health, the group states.
In addition, OSHA has "intentionally avoided raising or asking for comments" on this issue, ACOEM says, reflecting "an internal policy that federal standards should ensure that licensed health care professionals may practice independently of physician oversight."
ACOEM spokesman Pat O'Connor, a Washington, DC-based lobbyist for the organization, says the organization is merely trying to maintain the status quo established in all but four (methylene chloride, respirator, butadiene, and the TB proposal) of the most recent OSHA standards. About 20 previous standards do require physician supervision of medical surveillance, he states.
"It was only about a year ago when OSHA came out with the methylene chloride standard that they announced an internal policy to change the language. We want OSHA to open the rulemaking to reconsider the language and provide for a full opportunity for comment," O'Connor tells Hospital Employee Health. "We're saying, 'go back to the original language.'"
Will paramedics be practicing medicine?
He also says physician oversight of occupational health services already is required in most hospitals, so the proposed standard could change that policy and allow midlevel practitioners, such as nurse practitioners, registered nurses, licensed practical nurses, and even paramedics and emergency medical technicians to be in charge of employee medical surveillance.
"In certain situations, midlevel practitioners lack the competency, education, and training to make medical decisions that are critical to an employee's health," he maintains. "Nurse practitioners are pushing this for their economic interest, but when a nurse practitioner becomes the person ultimately responsible for a surveillance program, it's entirely likely under this [proposed] standard that in another instance, somebody without even the competencies of a nurse practitioner would be given those types of responsibilities. Midlevel practitioners want to practice medicine and not go to medical school. If OSHA feels that's appropriate, let's have a rulemaking record that demonstrates that."
O'Connor says ACOEM acknowledges that nurses and other practitioners such as physician assistants are "fully capable" of administering purified protein-derivative (PPD) skin tests, reading the results, and performing health assessments. However, he says, hospital protocols should provide for physicians to supervise the entire process by reviewing nurses' evaluations and to be called in when surveillance activities yield "questionable" or "abnormal" findings, such as TB infection or disease.
"We want protocols in existence to ensure that after a skin test is applied, the test is read, and the evaluation is made, a midlevel practitioner is not making an inappropriate medical diagnosis. The only way to do that is to make sure that a physician is ultimately responsible for the program," O'Connor says. "A midlevel practitioner can practice independently, but his or her actions [should be] reviewed by a physician on a regular basis."
But Adam Finkel, ScD, director of health standards for OSHA, says what ACOEM is proposing is contrary to state licensing provisions for nurses. Each state's requirements and licensed scope of practice for nurses and other health care professionals vary, he points out.
OSHA: 'They are picking a fight with us'
"They keep saying what we're doing is contrary to state practice and that's 180 degrees wrong. What we've done is to allow state licensure and practice to determine the outcome. They're unhappy that states have let certain advanced practice nurses practice independently, so they are picking a fight with us, when all we've done is say we're not inclined or qualified to say that some states are right and others wrong and we'll decide what's best," Finkel says.
Finkel also takes issue with the implication that OSHA does not heed public comments that are not specifically solicited or posed as questions in a hearing notice.
"There is no such thing as a public hearing for which anything is not up for comment," Finkel explains. "It's true that we raise certain issues in the notice of the hearing that put people on notice that we really want to make sure we hear about certain issues, but it is only because we're not so sure we would hear about them otherwise. It's not an attempt to give them more importance."
Furthermore, ACOEM's statement that the wording of OSHA standards changed only in the last year or two is incorrect, he says. The 1992 bloodborne pathogens standard also permitted LHCPs other than physicians to perform medical surveillance.
The charge that the agency's inclusion of LHCPs as independent occupational health practitioners limits workers' access to quality health care is "inflammatory and untrue," Finkel says. OSHA officials have considered testimony on all sides of the issue, and "we think we're doing the right thing for many reasons. We just don't start or end from the premise that the only person who can deliver quality occupational health surveillance is a doctor."
Both ACOEM and various nurses' associations have a clear professional interest in the welfare of their profession and members. "We don't want to get into a contest about who's protecting employees better, but we certainly think that's uppermost in our minds," Finkel says. "If the doctors want to say they're doing this all for the sake of workers, so be it, but that's what we think we're doing."
Concerns that paramedics could run occupational health TB surveillance programs at hospitals are "scare tactics," Finkel adds, because he does not know of a state that licenses paramedics to perform the medical surveillance activities required under the proposed TB standard.
Would OSHA consider specifying appropriate education, training, and credentials? If so, many physicians might not fare too well, he says.
If the agency were to specify additional requirements beyond state regulations, it could require health care professionals, including physicians, who participate in surveillance programs to have a certain amount of experience in occupational disease.
"We thought very seriously about that because it's the kind of training we want to see in the ideal world for people who are participating in these programs, but there are not a lot of people so trained to go around," he says. "A very small percentage of doctors are certified, and not a much greater percentage have had any training at all in occupational issues. How many hours of training does a physician need in occupational medicine to be a physician? Zero.
"If we open the door to any physician, and we close the door to occupational health nurses because they're nurses and not doctors, it's pretty clear that we would shut out a lot of people who have a lot of training in occupational health and open the door to a whole lot of people who have none at all," Finkel says.
Nurses provide most of the services
Susan Wilburn, RN, MPH, occupational safety and health specialist for the American Nurses Association (ANA) in Washington, DC, says ACOEM is attempting to limit the activities of nurses who are operating within their licensed scope of practice.
"Occupational health is a specialty of its own, and occupational health nurses are the largest majority of the providers of services, whether in the health care industry, which is what the TB standard mostly applies to, or in other industrial settings. It's the occupational health nurse who provides the health surveillance that is included in these OSHA standards in most cases," she says.
Nurses generally "are very clear" about practice limitations, she adds. Under their licensed scope of practice, advanced practice nurses are permitted to diagnose and treat occupational illnesses. Occupational health nurses, "certified or otherwise," can assess, provide surveillance activities, analyze trends, and develop exposure control programs to prevent injury and illness, Wilburn says. Their scope of practice and licensure are independent from physicians.
Managed care rears its head
"Part of the issue is that physicians are very concerned about what is happening with managed care and whether or not they're going to [be able to] continue to practice and have independent jobs themselves," Wilburn says. "There's been a national movement to provide managed occupational health and workers' compensation services, so a lot of independent occupational health physicians are left out when managed care organizations have their own managed workers' compensation systems with staff physicians."
Both the ANA, which represents the nation's 2.6 million registered nurses, and the 13,000-member American Association of Occupational Health Nurses (AAOHN) have filed with the U.S. Court of Appeals to become intervening parties in ACOEM's lawsuit against OSHA's respiratory protection standard. The nurses' organizations seek to retain the standard's broad language allowing nonphysician LHCPs to carry out medical surveillance requirements.
Kae Livsey, RN, MPH, governmental affairs manager for the Atlanta-based AAOHN, says the language issue is "the most important provision in this proposal to us." The organization has suggested to OSHA that the term "medical surveillance" be changed to "health surveillance."
"We need to think long and hard about what we're talking about," Livsey says. "These are health surveillance activities - prevention, not medical treatments. We're not medically monitoring [employees'] disease processes."
TB surveillance activities clearly fall within the scope of the registered nurse, she states.
"We see this as an attack on our ability to do what we're licensed and permitted to do and what we're fully capable of doing," Livsey adds. "As our scope continues to expand, we're running into this. It's a matter of turf. We don't see any evidence to indicate there's a quality problem, that the quality of care is less than it would be under the supervision of physicians."
While it may be a semantic point, Finkel says "health surveillance" vs. "medical surveillance" terminology raises a good point.
"Many of the activities we're envisioning under the TB standard are not really medical in the sense of diagnosis and treatment, but are more along the lines of monitoring and data collection, more routine things," he says. "A different term might make it clear that we're talking about a very broad set of activities, many of which doctors don't particularly want to do. They're the unglamorous part, the preventive services in which doctors aren't necessarily all that interested."
Reference
1. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,159-54,307 (Oct. 17, 1997).
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content