Career focusBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7067.2 (Published 16 November 1996) Cite this as: BMJ 1996;313:S2-7067
Academic and occupational physician David Coggon suspects that his specialty would be congenial to many doctors
Like many occupational physicians, I discovered occupational medicine quite late in my career. I was working for the Medical Research Council with an honorary NHS appointment as a senior registrar in general medicine and took on an epidemiological project looking at industrial causes of cancer. This brought me into contact with occupational physicians for the first time and I was attracted by what they told me about their work. I decided to train in the specialty myself, and I have never regretted it.
What do occupational physicians do?
Occupational physicians usually practise as part of an occupational health team, working alongside other professions, such as occupational health nurses, safety officers, occupational hygienists, and ergonomists. Occupational health is concerned with ensuring that people are fit to carry out their jobs and that they are not injured or made ill by the work that they do. In addition, the remit of many occupational health departments extends to the environmental impact of industrial processes and products on the health of the general public.
Specific tasks commonly carried out by occupational physicians include assessing the health of prospective new employees and advising about their fitness for particular jobs; advising about the rehabilitation and return to work of employees who are absent through illness; identifying, assessing, and advising about the management of health hazards in the workplace; monitoring the control of occupational hazards-for example, by targeted health surveillance-and educating managers and employees about health and safety issues. Specialist occupational physicians also often have managerial responsibility for the team in which they work. Occupational health departments in Britain do not normally provide treatment services other than first aid, but this may require input from the doctor, particularly where injury is serious or arises from an unusual hazard and requires specific treatment.
The work combines preventive medicine with the care of individuals in a way that is not found in other specialties. It requires a broad clinical knowledge of illnesses that occur in people of working age, the disabilities that they produce, and their prognosis; specialised knowledge of occupational diseases and their causes; an understanding of relevant industrial processes; and an appreciation of how businesses are organised. An aspect of my job that I have particularly enjoyed is the opportunity that it has given for visits to workplaces where I could see at first hand how products are made and experience the different management cultures that exist in British industry. The occupational physician has direct contact with staff at all levels of a company from senior management to the part time operative on the shop floor, and this gives a unique insight into its working.
As well as the core skills that are needed wherever occupational medicine is practised, special skills are required for particular jobs. Thus, a doctor working in the food industry must become an expert in food hygiene, while a colleague looking after divers on oil rigs will need a detailed knowledge of hyperbaric medicine.
It is a common misconception that occupational physicians function simply as advisers to management. While this is part of their role, they also provide advice and care to individual employees, operating under the same duty of confidentiality that applies to any doctor. This applies whether the individuals have referred themselves or have been referred by management. Conflicts of interest between employer and employee are rare in practice, but where they occur there are clear ethical guidelines on how they should be handled.
Advantages and disadvantages of a career in occupational medicine
Combines effective preventive medicine with the care of individual patients
Opportunities to work in many different management cultures
Opportunities to take on new jobs and new challenges right up to retirement
Scope to develop a special interest and become a national or international expert
Good opportunities for part time work and career breaks
Most jobs do not entail an on call commitment
… and potential drawbacks
Relative isolation from medical colleagues in some jobs
Some companies demand flexible working patterns with substantial periods away from home
Pension arrangements outside the NHS may be less favourable.
Where do occupational physicians work?
Most of the doctors who practise occupational medicine in Britain are general practitioners with a part time interest, but there are about 500 specialists, most of whom work in private industry, mainly for larger companies which may employ several doctors. Until recently the NHS had only a rudimentary occupational health input, but now a growing number of trusts have consultant led departments which not only care for hospital staff, but also contract services to other local employers in both the public and private sectors. Other organisations employing occupational physicians include the Health and Safety Executive, which formulates and enforces health and safety legislation, the armed forces, and local government. In addition, several universities have academic departments of occupational and environmental medicine which carry out both teaching and research.
Scope for job mobility that exists right up to retirement age. It is not unusual for occupational physicians to progress through three or four different industries in the course of their careers. For example, one of my colleagues started out with the National Coal Board, then moved to IBM, and now combines work in an academic department with an NHS consultant appointment.
Training in occupational medicine
The arrangements for training in occupational medicine are overseen by the Faculty of Occupational Medicine of the Royal College of Physicians in conjunction with the postgraduate deans. As in other disciplines, it entails a period of general professional training followed by specialist training.
General professional training is for a minimum of three years, including preregistration house jobs, and can be undertaken in a wide variety of posts. Experience in general medicine is particularly useful, as is training in respiratory medicine, dermatology, rheumatology and rehabilitation, accident and emergency, psychiatry, ophthalmology, or general practice. Many trainees enter occupational medicine having worked previously as general practitioners and meet the requirements for general professional training by virtue of their vocational training in general practice.
There is no mandatory qualification for entry to specialist training, but possession of the membership of the Royal College of Physicians or Royal College of General Practitioners is an advantage. In this phase the trainee must work for the equivalent of four years full time in one or more supervised posts that have been approved by the Joint Committee for Higher Medical Training on behalf of the Faculty of Occupational Medicine. Up to 12 months of this time can be spent on formal academic courses such as for an MSc, and a further 12 months may be allowed for relevant research. Posts are approved in both the private and public sectors (including the armed forces) and sometimes rotate between the two. The training is designed to cover a prescribed curriculum, and the progress of the trainee is monitored at annual assessments.
In addition, it is necessary to obtain associateship and then membership of the Faculty of Occupational Medicine (AFOM and MFOM). The AFOM examination is normally taken one to two years into specialist training. It currently comprises two written papers, a multiple choice paper based on projected slides, two oral examinations (one of which focuses on a journal submitted by the candidate in advance), and a clinical examination with long and short cases. The pass rate is usually about 50%. Most candidates prepare for the examination by undertaking a course at one of the university departments of occupational medicine, often with funding from their employer. For the MFOM the trainee must successfully submit a dissertation or published research on a relevant topic, equivalent in length to an MSc thesis.
Getting a first job
The most difficult step in training is getting a first job in occupational medicine. Specialist registrar appointments in the NHS are advertised in the BMJ, as are some training posts in industry. Not all jobs are publicised in this way, however, and doctors who are looking for an opening should also consider joining the Society of Occupational Medicine which circulates advertisements for jobs in its regular mailings to members. Another way forward is to obtain a job in industry which, although not approved for training at the time it is advertised, has potential for recognition as a training post. Further advice about this can be obtained from the Faculty of Occupational Medicine, 6 St Andrew's Place, London NW1 4LB, where the society is also based.
Once training has been completed, moving on to a consultant appointment or equivalent post outside the NHS is not too difficult.
Pay and future job prospects
Within the NHS, universities, and armed forces, occupational physicians are paid on the same scales as other doctors of equivalent grade. Salaries in industry are privately negotiated, and although the BMA publishes guidance on the rates that might be expected (similar to those in the NHS), individual doctors may do better or worse. Many contracts include extras such as a company car, annual bonuses, share options, private health insurance, and relocation expenses. On the other hand, pension arrangements are not always as good as in the public sector.
As would be expected, the availability of work in the private sector is influenced by the prevailing economic climate, but prospects for the foreseeable future look good. Although some larger companies have reduced the size of their occupational health departments in recent years, many smaller businesses are looking for greater medical input, particularly in response to new health and safety legislation. Ministers have pledged a continued expansion of occupational health provision in the NHS, a trend strongly supported by the BMA.
Occupational medicine offers good opportunities for those who want to work part time or take career breaks-for example, because of family commitments. Moreover, most jobs do not entail an on call commitment.