R E S E A RC H

History and development of training in occupational medicine Pete r Wes te r h o l m

S U M M A RY

After a reminder of the wide scope of the subject of occupational medicine, the issues of training are described as set in a context of societal and professional development. Undergraduate training will be touched on, referring to experiences from the UK. In discussing the training of specialists in occupational medicine, reference is made to experiences gained in Norway. The implications for training and education, occasioned by major changes in roles and tasks of the occupational medicine professionals, will be commented on while observing developments in the Netherlands. The links between training and the need for competencies in the reallife context of a health market will be touched on. After a short reminder of the European aspects of occupational medicine specialist training, attention is directed towards the extreme patchwork nature, amounting to absence in important aspects, of documentation of the history of the development of training and education in occupational medicine. This also applies to the evaluations of strategies aiming at change and development of programmes for vocational training on undergraduate, graduate and postgraduate levels, including programmes for sustaining competencies and competence development.

HISTORY, OCCUPATIONAL MEDICINE, EDUCATION, TRAINING, PROFESSIONAL TRAINING, EXAMINATION

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In the preparation of this address dedicated to my dear and long-time friend Professor Raphael Masschelein, on the occasion of his official retirement from his professorial chair at the Catholic University of Leuven, it dawned on me that I was facing the most awful difficulties. The subject chosen for me was the one given above – the history and development of training in occupational medicine. So, the first elementary step was to look for relevant literature. I soon found that there is only very little documentation on this subject readily available. In an international perspective most documentation in European countries is in national languages not easily accessible to all. In opting for documents in English or French there is more choice, but even then the researcher is confronted by a conspicuous lack of overviews and analyses of important trends and strategies, not to mention underlying motives for change and development. And, of course, there are even fewer explanations of non-action or downgrading by agencies and persons responsible for this whole issue of training of physicians and other health professionals in the field of occupational medicine.

So, in advance I have to announce that at the end of this day the history of training and development remains a tale to be researched and told. There is a significant scarcity of data and documentation. The core questions for this paper might therefore be reformulated: how to sketch the historic development of the professional domain of occupational medicine, and what are we able to learn from the past and the present for the future of training? I shall now share with you some historic snapshots, chosen at random, drawing on experiences and observations of developments in three selected countries – the UK, the Netherlands and Norway. The UK was selected for its proper documentation of the development of professional societies of occupational medicine, the Netherlands for the fast-track development of the present-day system in clearly distinguishable intermediary stages, and Norway for its carefully considered system for training specialists in occupational medicine. Hopefully these snapshots will provide enough incentives for younger colleagues for further exploration of the history of the field for which we share a commitment – research and practice in occupational medicine. O C C U PAT I O N A L M E D I C I N E – THE DOMAIN

For the purpose of focussing on the subject matter of this symposium I will begin with referring to a few definitions of the concept of occupational medicine. They have been drawn from dictionary sources and here follows a selection, supplemented with their respective internet links. So, occupational medicine may be: |

the practice of medicine concerned with injury and illness in the workplace. www.bcbsmt.com/ Providers_specialtydefs-physicians-o-p.asp

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a specialty devoted to the prevention and management of occupational injury, illness and disability, and the promotion of the health of workers, their families, and their communities. sis.nlm.nih.gov/enviro/iupac glossary/glossaryo.html

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treatment of disease/injury and promotion of health in the work site. www.ohiohealth. com/blank.cfm

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a branch of medicine concerned with the treatment of patients with occupational and environmental illness and/or injury. www.case. edu/med/epidbio/mphp439/Dictionary.htm

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care and treatment of work related illness or on-the-job accident or injury. www.centuryhealth.com/glossary.asp

There are certainly many more definitions to be found. These examples will do for the moment. The first one on the list is rather generally worded, in that it addresses the subject of medical practice related to injury and illness in the workplace. No reference is made to prevention or indeed to any conception of health. The last three definitions on the list move towards treatment and curative activities. The second item listed includes prevention and management of occupational injury, illness and disability not only for the workers but also for their families and communities. Health promotion is clearly on the agenda according to this definition. It exhibits a broadness of scope that brings it close to the concept most of us in Western Europe cherish today. The aspect of also providing a broad range of health services to families of staff employed in client companies may not agree with all countries’ national health service systems. This is, however, not the most important aspect in our present discussion. I am bringing up this list of definitions because it is a reminder of the different ideas and concepts underlying occupational medicine as a specialized field in clinical medicine. It carries implications for training and development. All programmes for training and development in occupational medicine need, for obvious reasons, to be formulated with a view on what a highly qualified training is to be used for. Curricula for training of occupational medicine specialists are to be adapted to what is expected from them by clients and customers. It does not come as a surprise to observe considerable inter- and intra-country differences when looking at curricula and programmes for the training of occupational physicians in Europe and elsewhere. Using these definitions the domains of occupational health prevention, health promotion, occupational rehabilitation, occupational injury

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management and treatment etc. can be broken down into a further 20 to 30 specific areas or categories to be addressed in formulating a competence profile for the occupational medicine specialist. This conceptual ambiguity needs to be kept in mind in discussions about objectives and methods in vocational and academic training of occupational medicine specialists. The scope limits of occupational medicine, and equally of environmental medicine, are difficult to define. In the broadest sense occupational medicine embodies all aspects of the relationship between work and health, thus also including the impact of disease and ill health on the capacity to work, regardless whether or not that work has contributed to its development. This aspect deserves some attention when looking at training programmes aiming at occupational medicine professionals’ needs. In this paper the concepts of Occupational Medicine and Occupational Health will be interchangeable. CHANGING THE REMIT OF O C C U PAT I O N A L M E D I C I N E

A historic overview of the development of occupational medicine and of the occupational health services is shown in table 1, conceptually devised by Professor Jorma Rantanen, Finland, currently President of the International Commission on Occupational Health (ICOH). The table aims to demonstrate major trends in the development of occupational medicine in Finland – and, by extension, in many other countries. In broad terms the emphasis on an occupational medicine agenda up to the 1970s was predominantly curative, with work programmes very similar to primary health care organizations in societies at that time. For a long time the health concept was largely

| In most European countries, the history of training in occupational medicine is a tale of struggle for recognition: in the academia, in the health service systems, and in the health professions. | Interaction between the state, the civil service, the professional training institutes, the market and the professional societies has determined the outlines of programmes and curricula in training of occupational medicine. | Countries differ significantly in requirements for a specialist degree in occupational medicine.

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Table 1 Stages of development of occupational medicine of Finland1 Stage I (1950–1970) Stage II (1970–1990) Non-specific Specific Curative / reparative services Prevention of hazards and risk exposure Passive Active Disease oriented Primary care

Medical specialization Prevention

operationalized as an absence of disease, and the disease concept was in its turn based on the state of affairs in medical pathology and clinical medicine. In the second half of the 20th century a wind of change focussed attention on environmental conditions and working conditions in particular. Occupational medicine sought an active role in the identification of hazardous agents and factors causing strains and stresses at work. The prevention of ill health and injuries became prominent in occupational medicine agendas of the day, replacing, at least in part, the orientation on curative action in many countries. The health concept commonly used followed the well-known WHO definition of 1948 defining health as a ‘State of complete physical, mental and social well-being and not merely the absence of disease’. Towards the end of the century the first signs showed in Europe of establishing occupational medicine as a medical specialty. The right-hand column of the table represents our current situation with an increased awareness of work organization factors, including personnel management, as important determinants of health and well-being at work. The importance of a holistic vision of mankind at work and in society is emphasized. New health professions enter onto the stage and the concept of multidisciplinarity in occupational health service performance becomes increasingly prominent in the minds of occupational health professionals and in public awareness.

Stage III (1990–now) Holistic Oriented towards development and health promotion Intervention in work organization and life-style of groups and individuals Multidisciplinary integrated action OHS as a resource in developing organizations and people

This development has obvious implications for the training of health professionals, and, as it increasingly has turned out in many countries from the 1990s, for the training of specialists in occupational medicine. O C C U PAT I O N A L M E D I C I N E – DEPENDENCE ON SOCIO-POLITICAL CONTEXT

The Netherlands is a particularly interesting country to observe for the training implications in occupational medicine in view of the fast changes and quick turn-arounds during the most recent two decades. It exemplifies a fast-track development implying concrete and substantial changes in work tasks, responsibilities and roles of occupational medicine professionals, most of it happening within a time-span of ten to fifteen years (table 2). The Netherlands case is particularly interesting and educational as this country went through very drastic changes in its organization and its client systems within a condensed space of roughly 15 years time. It is a riveting story giving us much to learn and to reflect on. The history of this development was reviewed by A. Weel and N. Plomp in 2007.2 What consequences did this entail for the training of occupational medicine specialists and other occupational health professionals? In the early 1990s there was already a strong emphasis on interdisciplinary collabora-

Table 2 Stages of occupational medicine development in the Netherlands 1900–1945 1946–1959 1960–1980 1980–1994 1994–1999 1999–2008

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Pioneer stage. Focus set on occupational accidents and diseases. Poor working conditions. Tuberculosis a serious public health hazard. Expansion of professional OH services. Professional society 1946 (NVAB). OHS extending countrywide, based on supportive legislation. Consolidation. Public health role of occupational health services. Prevention of CHD seen as an important task in occupational medicine. Other OH professionals enter the stage. OH physicians gradually lose their managerial role. Legal obligation for employers to affiliate with an occupational health service provider. OH physicians’ role and tasks regulated. Compulsory quality certification of occupational health service providers. Monopolies lost. Tightening of responsibilities of employers and employees. Absence management and return-to-work programmes increasingly important tasks for professional OH organizations and occupational medicine specialists

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tion, knowledge about structure and functioning of organizations, management approaches and even commercial techniques (the latter since 1994) in the curricula for training of occupational physicians in the Netherlands. It appears this was judged to be quite appropriate and no further changes were therefore called for. This is certainly an interesting observation. Which other countries of the European Union were able to arrive at such an evaluative judgement at this time? O C C U PAT I O N A L M E D I C I N E – U N D E RG R A D U AT E T R A I N I N G

To remind us of how undergraduate training in occupational medicine could be organized in recent history I have selected the UK as an example. The undergraduate medical student curriculum in the UK has been admirably described and commented on in an outwardly modest, but at the same time well-edited and well-considered document with contributions by experienced authors, several of them well-known internationally in connection with the history of occupational medicine. We can regard it as a snapshot taken by John R. Glover in the UK in 1970.3 Here follow some of the most salient points. | Occupational medicine (OM) was taught in 21 of 28 medical schools in the UK and Northern Ireland. | OM taught in 22 medical school departments with 15 different titles – Departments of Medicine (or sub-groups of such departments), Department of Public Health, Department of Preventive Medicine & Public Health, Department of Social and Occupational Medicine, Department of Social & Preventive Medicine and ten additional departments, all with different titles and title combinations. | In the pre-clinical stage an average of 26 hours spent on curriculum lectures including bedside teaching (9), factory visits (15) and seminars (2). | 20 medical schools teach undergraduates from 2 to 124 hours in clinical stage – a considerable variation carrying implications with regard to physicians’ subject knowledge after having passed final examination. | Specific examination questions practised for final qualifying examinations in 11 (of 21) medical schools So, the UK scenario of 1970 represents occupational medicine as an academic subject and subject matter of undergraduate training that is marked by a considerable diversity. The report edited by John R. Glover contains extremely read-

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able and profoundly reflected upon comments on the nature of occupational medicine (J.A. Smiley, C.R. Lowe), the relationship with the realm of occupational health (T.S. Scott), didactic teaching (R.S.F. Schilling), the factory visit (G.L. Leathart), project work (R.I. McCallum), the clinical ward round (G. Katzanzis), rehabilitation (C.I. Mann), to select a few of the rubrics and subjects familiar to us all. The fundamental ideas and concepts are very much the same as those applied today in our current undergraduate training practices in many European countries. It is to be observed that the setting of this undergraduate training was the academic medical school with the conventional white-coat hierarchy characteristic for such establishments at that time. Keeping this in mind it is refreshing to see how the basic principles of knowledge transfer were implemented in a professionally effective way, paying attention to the nature of occupational medicine as a subject in clinical medicine. For example the chapters on ward round and factory visit teachings convey the refined wisdom of committed and experienced teachers, all of it seasoned with the reminders of what was earlier referred to as good bedside manners – in the setting of occupational medicine as practiced today. A minor part of training was delivered as formal lectures in the setting of a classroom. Students’ comments in the report indicate that the small group sessions led by competent tutors were by far the most popular and seen as effective. TRAINING OF P O S T G R A D U AT E P H Y S I C I A N S

The experiences in the UK regarding training of undergraduates in occupational medicine are very much the same as in many other European countries. The general bottom-line observation is that this meagre basic level teaching is not sufficient for professional performance in this subject in a health service organization, private or public. Beginning in the 1990s many countries introduced occupational medicine as a specialty of physicians to be qualified for by documented, structured and qualified training, in some countries including a written and/or oral examination. Countries differ significantly in the regulating qualifications required for a specialist degree in the specialty occupational medicine. An overview of the situation in Europe was published by the Glasgow University in a workshop report edited by Ewan Macdonald in 1997.4 This is a landmark document in establishing the situ-

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ation in Western Europe at the time. The regulations in many countries implied requirements of work experience during a specified period of time in a specified post in occupational medicine in the field and theoretical tutoring/training. For this occasion I have selected Norway to represent countries that have introduced a structured programme for physicians wishing to qualify as occupational medicine specialists. The Norwegian curriculum is outlined below: | five years work in occupational medicine; | of these five years one year must be in an occupational health centre or a recognized training institution for occupational health / occupational medicine; | one year must be spent in a research institution; | one year must be spent working in social medicine; | one year must be spent working in a department or institution of an occupational medicine-related orientation; | one year must be spent working in an institution of community medicine or general primary care medicine; | during principal two-year period of specialty training 300 hours of tutoring plus training on specified subjects. During these years of training in the posts specified above the physician is required to attend seminars and teaching events in classroom situations with organizations/establishments of approved competence. The subjects taught are: | legislation (30 hours); | management, leadership, development of organizations (30 hours); | project organization, management and methods in occupational medicine (40 hours); | environmental medicine (35 hours); | occupationally related musculoskeletal pain syndromes (20 hours); | psychosocial strains and stresses (20 hours); | psycho-somatic illness & disease (5 hours); | toxicology (20 hours); | lung and airway disease (15 hours); | skin disease (15 hours); | neurology (15 hours). Norway provides an example of countries with arrangements for locating the greatest part of specialty training in the years following the basic examination after concluding university medical training. With this arrangement teaching and tutoring is limited to the category of physicians

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actively choosing occupational medicine (occupational health) as their professional career. H I S TO R I C A L FA C TO R S INFLUENCING TRAINING IN O C C U PAT I O N A L M E D I C I N E Industrialization – social and political fac to rs

The technical development of production and services in companies in practically all branches of industry and in the service sector is an obvious driving factor and incentive for specialization of occupational health professionals. During the last decades changes in production have entailed a shift of the earlier focus on physical and chemical hazards and accidents (stages I and II in table 1) towards an emphasis on psychosocial stressors at work and features of the organization and personnel management-leadership in the workplace (stage III). The priorities have now shifted towards health promotion and concerns about recruiting and retaining qualified and competent staff members. Fac to rs i n re c e n t h i s to r y – Wor l d Wars I and I I

In Europe the World Wars involved most countries in both combat and non-combat activities. They certainly created a need for curative and reparative health services. It is quite reasonable to maintain, however, that the wars also contributed towards creating an awareness of the need for professionals capable of managing preventive and protective health in armed forces as well as in the civilian segments of the population. D eter minants – S tate p ol icies on public health

This refers to the fundamental issue of whether occupational health / occupational medicine is a scientific academic discipline with institutions charged with promoting competencies in the interests of public health, or if they are to be seen as subservient to the commercial needs of industry and other companies. This is and has been a steadily recurring issue over the years. It carries implications for the funding and organization of programmes for the training of health professionals. This is also a determinant for the development of occupational health services to the working segment of the population. In the UK for example, occupational health care has been excluded from the National Health Service (NHS) from its conception. As it was perceived to be in the best interests of employers to organize such

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services themselves, it was felt that funding by employers was a convenient solution. This also has had, and still has, implications for the funding of training programmes. The recent policy report submitted to the UK Government by Dame Carol Black in March 2008, entitled ‘Review of the health of Britain’s working age population – working for a healthier tomorrow’ may, however, be conducive to a political reappraisal of this position.5 Barriers in attending physicians

There is widespread agreement that physicians are inadequately trained in occupational medicine. There has been, however, and still is to a significant extent, resistance among general physicians and also among others to involve occupational health colleagues in the management of workers seeking medical advice concerning health problems related to work. This resistance has been a factor inhibiting the development of the occupational medicine specialty. There are numerous constraints to the active participation by primary care physicians. These may, beside lacking competence, be: | occupational events are often difficult and time-consuming to diagnose; | lack of information for the primary care practitioner | lack of payment for preventive activities; | lack of understanding or hesitancy with regard to legal issues involved; | ethically difficult situations may arise, particularly when the occupational physician is employed by the patient’s employer. The US National Academy of Sciences published a report in 2007 on the issues confronting primary care physicians who become involved in the practice of occupational medicine.6 T h e p ro f es s i o n a l o rg ani zat i o ns and journals

A determined effort by the professional organizations has proved to be an important factor in achieving recognition and developing competence development in occupational medicine. In the UK the Faculty of Occupational Medicine was formally established and came to be a powerful driver for the development of training programmes for specialty examinations. In 1980 the first Guidelines on Ethics for Occupational Physicians were published by the Faculty and in 1984 the General Medical Council (GMC) of the UK recognized the Faculty Fellowship FFOM and also Faculty Membership MFOM as registration of specialist qualifications. See Dudley Bruton7

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for an account of this fast development and the active involvement of the Faculty in organizing training and examinations during the years 1978–2003. As for the developments in the UK, the role of professional journals should be recognized as important carriers of professional experience and information on advances in scientific knowledge. Tim Carter described the arrival in 1945 of the British Journal of Industrial Medicine – later to become the Occupational and Environmental Medicine journal – and the Journal of the Society of Occupational Medicine which was to become the Occupational Medicine journal in 1992.8 These instruments of determined and dedicated editors came to be powerful tools in contributing to the development of a sense of professionalism and self-confidence among occupational health professionals. The formation and development of professional associations other than for the occupational physicians was described by Carter in 19859 and by Carter et al. in 2000.10 Science has entered the stage, bringing with it the drive to develop knowledge and evidencebased practices to be taught in all stages of professional training. GENERAL PERSPECTIVES IN THE T R A I N I N G O F O C C U PAT I O N A L MEDICINE SPECIALISTS

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Occupational medicine is a component of the health and safety systems operating on both societal and enterprise levels with a need for concerted interaction with representatives from both sides. There is a complicated set of stakeholders where often no clear priorities can be identified. Work tasks of occupational physicians are demanding more and more evidence-based practice, work tools and management skills. Occupational medicine is practiced in health and safety systems where three basic models for management of human activity – hierarchy, market and networking – co-exist in parallel. Three domains are expected to be aligned for optimal functioning in carrying out practical tasks – the domain of health professions, the administration domain and the leadership domain (political or non-political). This may lead to ambiguity in accountability. Occupational medicine is a health and safety field carrying complexities and challenges to professional ethics.

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Occupational medicine training institutes might learn a lot from the study of processes taking place in curative medicine regarding new scientific achievements.

Recent achievements like drug development using genetic-pharmaceutical models, stem cell therapy for malignancies, and imaging techniques for diagnostics and adjuvant therapies all have been realized under constraints imposed by budgetary frameworks and cost-containment programmes, with an anticipation of the readiness on the part of the health service organization to adapt. I am referring here to these developments since they have become possible due to the dynamics of interaction between the state, health authorities, scientific institutions, health professionals and sponsoring agencies. We are likely to find much to learn from studying these processes as well for vocational training in occupational medicine.

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| T R A I N I N G O F O C C U PAT I O N A L M E D I C I N E P RO F E S S I O N A L S – SOME OF THE CHALLENGES

First, we are well advised to recognize occupational medicine as related to health service systems in general and to their specific features, well known to us: | health services constitute societal welfare systems setting demands and expectations for joint action in pursuit of health objectives; | multiple stakeholders none of whom have a self-evident predominant role; | demands on evidence-based knowledge and methods; | health services combining three pathways for management of human activity – hierarchy, market and networking – operating simultaneously and in parallel; | three domains to integrate – the professions, the administration and the actors on the political level; accountabilities and responsibilities may become muddled; | health services operate in a field where sometimes complex ethical challenges need to be managed. Second, we have the following circumstances to take into account: | undergraduate training is meagre; subject of occupational medicine commonly in Cinderella state, introduced in late curriculum stages of undergraduate training; | training of occupational medicine specialists

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after final MD exam; adult pedagogics required in vocational specialty training and practical case management, both on individual case level and on collective (enterprise or department) levels, represent effective training strategies; shortage of competent tutors and teachers; need to apply methods of distance learning in using up-to-date means of communication; necessity to equip students with competencies to handle the needs and demands of clients and client systems in a professional way; in aiming to achieve factual competence and to sustain occupational medicine professionalism in a societal context, it is essential to stay aware of constantly ongoing renegotiations of societal contracts for all health professionals; this also includes the inflow of new professions into the realm of occupational health; it is an indispensable strategy to make evaluations of policies and programmes – including training programmes; in implementation a means of continuous learning and a means of communication within and between countries.

C O N C L U D I N G C O M M E N T S – W H AT I S T H E R E TO L E A R N F RO M H I S TO RY ?

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The history of academic and vocational training in occupational medicine is a country and culture specific narrative that to a large extent remains to be written. The outlines of programmes and curricula for training occupational medicine specialists and occupational health professionals in general are outcomes of the interaction between actors representing the state, the civil service (bureaucracy), the professional training establishments including universities, the market and the professional societies. It is a research field in its own right. It needs and deserves to be explored and written. There are most likely valuable lessons to be learned in this field concerning future developments in expectations about quality and competence demanded from occupational health professionals by the societies / populations served. In most European countries this history is a tale of a struggle for recognition, in the academic world, in the health service systems of countries and in the health professions. It is a tale of emergence of professionalism, to be continuously sustained and sharpened under existing conditions of societal develop-

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ment. We would need our friend Raphael Masschelein to be with us in exploring this domain where we are likely to find so much to learn, and to bring to optimal use the networks of the EASOM organization, chaired and led by Raphael during many years marked by success. We are told that medical genetics has been among the disciplines contributing in a great way to recent developments in clinical medicine. Have we arrived at a stage where it is possible to ask for a cloning of Raphael Masschelein in order to provide us with 50 or so more of him – in view of the challenges we are facing? They would all be needed. We may, however, still be too early in that particular development to harbour such an idea.

REFERENCES 1. Rantanen J. Keynote address at ICOH Scientific Committee on Education and Training Conference in Glynhill Hotel, Glasgow, Scotland, May 10th–11th 2008. Organized by the School of Public Health, University of Glasgow. 2. Weel ANH, Plomp HN. Developments in the occupational health services in the Netherlands. In: Westerholm P, Walters D (Eds.). Supporting health at work – international perspectives on occupational health services. Institute of Occupational Safety and Health (IOSH), IOSH Services Ltd (UK), 2007. 190 pp., ISBN 978 0 901357 39 7. 3. A Symposium at the Royal College of Physicians on Occupational Health for the Undergraduate Medical Student, Thursday, May 14, 1970 at the Royal College of Physicians, London , UK. Report (Ed. John R. Glover, Society of Occupational Medicine, UK). 4. Macdonald EB, Ide C, Elder A (Ed.). Competencies of occupational physicians – requirements of occupational medicine training in Europe. Proceedings of a Conference held in Glasgow in April 1997. Glasgow:

University of Glasgow, 1997. Black C. Working for a Healthier Tomorrow 2008. Dame Carol Black’s review of the health of Britain’s working age population. www.workingforhealth. gov.uk/documents/working-for-a-healthier-tomorrowtagged.pdf. 6. National Academy of Sciences, Division of Health Promotion and Disease Prevention. Role of the primary care physician in occupational and environmental medicine. National Academy of Sciences 2007 (97 pp.), www.nap.edu/openbook.php?record_id=9496. 7. Bruton DM. The Faculty of Occupational Medicine – the first twenty five years. (Ed: Robin Cox). Faculty of Occupational Medicine of The Royal College of Physicians, London, 2003. 8. Carter T. The three faces of occupational medicine: printed paper, problems in practice and professional purpose. Occup Med 2000; 50: 460–470. 9. Carter Tim. Fifty years of medicine in the workplace. J Soc Occup Med 1985 (Jubilee issue): 4–22. 10. Carter T, Atwell C, Wilson H. Occupational health professions in the United Kingdom. In: Grieco A, Fano D, Carter T, Iavicoli S. (eds.), Origins of occupational health associations in the world. Amsterdam: Elsevier Science, 2000, pp. 255-264. 5.

ABOUT THE AUTHOR Peter Westerholm was Professor in Occupational Epidemiology to the National Swedish Institute for Working Life from 1989 to 2000 and Chairman of the International Commission on Occupational Health (ICOH) scientific committee on ‘Health Services Research and Evaluation in Occupational Health’ from 1992 to 1999. CORRESPONDENCE ADDRESS Prof. Peter Westerholm MD FFOM, Professor emeritus, Uppsala University, Department of Medical Sciences, Occupational and Environmental Medicine, Ulleråkersvägen 38–40, SE – 751 85 Uppsala, Sweden. Email: [email protected].

NEWS

Less sickness absence by using adalimumab Patients with RA receiving adalimumab experienced significantly longer periods of work and continuous employment, than did those receiving DMARDs. The mechanism by which adalimumab decreases likelihood of stopping work appears different from that of DMARD therapy and independent of clinical responses. Data from an open-label extension study (DE033) of 486 RA patients receiving adalimumab monotherapy (who previously failed a DMARD) were

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compared with data from 747 RA patients receiving DMARD therapy in a Norway-based longitudinal registry. During a 24-month period, the 158 adalimumab-treated patients who were working at baseline, worked 7.32 months longer than did the 180 DMARD-treated patients. Patients receiving adalimumab worked 2.0 months longer and were significantly less likely to stop working than those receiving DMARDs. Source: ARD, October 1, 2008

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