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The central problem in occupational medicine is the artificial distinction between work-related and non-work-related injuries and illnesses. From a medical perspective, there is no need to maintain a separate system of care and compensation for work-related medical problems. While special expertise may be be necessary to evaluate and treat the special risks of workplace toxic exposures, hair-splitting over the contribution of the workplace stress to a patient's heart attack is a legal rather than a medical issue. This arbitrary separation affects all occupational medical practice. It poses serious legal and ethical problems when the employee-patient does not have adequate health care and disability coverage for general injuries and illnesses.

Employers must pay the medical and disability costs of all work-related injuries and illnesses. Medical services are provided either directly by employee or contract physicians or indirectly through worker's compensation claims for care provided by independent physicians. In most states, employers are not required to pay for or offer group health insurance. If the employer does not offer coverage for the employee's general medical needs, the employee may be able to pay for care only for work-related illnesses and injuries. This presents a problem because the law expects a physician to manage all of the patient's medical needs, consistent with that physician's specialty practice limitations. (See Chapter 9.) Even when these needs are beyond the physician's area of practice, there remains the duty to refer the patient to an appropriate specialist. This usually does not present a problem for a company-based occupational medicine specialist. Such specialists are in a clearly limited practice situation and may justifiably request that their patients go to a community physician for general medical care. More important, most companies that have in-house medical departments also provide their employees with group health insurance, making it possible for the employees to afford private general medical care.

Family practitioners or internists who offer occupational medical services in addition to a general office practice will not be able to assert that an employee-patient's general medical needs are beyond the scope of their practice. When such physicians detect general medical problems while providing occupational medicine services, they may refer the patient to an appropriate indigent care provider. The problem arises when there is no other provider willing to accept the patient for general medical care. Ethically, contract occupational medicine physicians cannot continue to see patients for work-related conditions while ignoring the patients' general medical problems. Legally, it will be difficult to convince a jury that it was reasonable to fit the patient's medical care to the contract with the employer. Even company-based occupational medicine providers must care for general medical problems if proper referrals are impossible. A private physician should be cautious about agreements to provide occupational medicine services for an employer that will not pay for necessary general medical services that will otherwise be unavailable to the employees. A physician who agrees to provide care in such a situation should be prepared to provide such other care as is necessary without payment.

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