Case study 8: Mr A Risk

This gentleman presents with angina. As part of the history taking, what do you need to know about his occupation?

Essentially, you want to know what hazards (physical, chemical, psychological - and less importantly in this case - biological hazards) exist in the workplace:

• Is the job physically demanding, i.e. are physical work-tasks such as lifting and carrying likely to provoke angina?
• Are there environmental stressors such as heat or cold, e.g. work in a freezer or foundry?
• Is there any exposure to chemicals that may aggravate ischaemia, such as methylene chloride in paint stripper, which is metabolised to carbon monoxide? Is there exposure to carbon monoxide itself, from traffic fume or foundry work?
• Is the job inherently 'stressful'? There is evidence that a combination of high demands at work and low job control increases cardiovascular mortality risk.

You also need to know whether there are any legal restrictions in relation to ischaemic heart disease applying to his job. For example there are restrictions on driving Large Goods Vehicles and Passenger Carrying Vehicles, flying or controlling aircraft, working off-shore or in the Merchant Navy.

From your understanding of the hazards at work, how would you assess his risk?

Risk depends on how much of the hazard he is exposed to. For example, if he is the manager of a frozen foods business, he may need to go into the freezer a couple of times a week. If he is a warehouseman in that business, he could be in sub-zero temperatures for 8 (or more) hours per day.

At this stage you have an intriguing set of possibilities concerned with the links between Mr Risk and his occupation. These are as follows:

• The angina may have been caused by his work (very rare) or aggravated/contributed to by it (a little more common),
• He may believe that the angina has been caused by his (still quite rare) or aggravated/contributed to by it (quite common),
• There may be factors in the job (hazards) which due to their frequency/intensity (risk) may impact on his capacity to work.

These two issues, illustrated by these bullets, are at the core occupational medical practice. They are:

• The effect of work on health,
• The effect of health on capacity to work.

There is a large body of knowledge and expertise attached to these issues especially in an ageing society where people with an accumulation of different medical conditions may have to work longer and, paradoxically, are less inclined to do so in practice.

How would you deal with the two following scenarios?

Scenario 1

Mr Risk comes to you as his doctor. He says that his job as a frozen-food warehouseman has aggravated his angina or has irritated it. He wants you to support his claim. A couple of weeks later you get a letter from his solicitor inviting you to do this.

• What do you say and do?
• What are the implications of supporting his claim?
• What are the implications of not supporting it?

Make some notes on these possibilities and try them out on some of your colleagues. See what they think.

Scenario 2

Mr Risk says he wants you to sign him off because his job in the frozen-food warehouse is too heavy for him. So you sign him off. Mr Risk asks you to write to the employer saying this and suggesting a lighter job. You do this. The employer writes back saying there are no lighter jobs and implying that Mr Risk's job was very light anyway. They send a formal risk assessment of the job which seems to confirm this.

Mr Risk continues to decline to do the job. You continue to issue certificates. Eventually Mr Risk is sacked on the basis that he continued not be available for work as certified by you.

Is this a useful outcome? It is certainly common. If you wanted to, how could you have helped prevent it? Think about the issues which can feed conflict in these situations. It helps to write down about half a dozen factors which impinge on it. Positively, identifying these may help you to help you patient. More cynically, being aware of them may help you to avoid being sued.

How would you get him to reduce his risk, both from non-occupational and occupational factors?

Clearly he needs to reduce his risk by stopping smoking, eating a low fat diet, taking exercise and taking appropriate prescribed medication.

He also needs to assess his work, to see if hazards need to be changed or reduced. This is best done in consultation with his occupational health department (if he has one at work). An occupational health professional is in the best position to advise on risk reduction related to specific work-place exposures as above.

This ties in with the confrontation we have just discussed above. Draft a letter to the employer’s occupational health department. It should contain clinical and treatment details and your estimate of the effect of the angina on your patients physical capacity to do activities.

There is plenty of clinical and sociological evidence that being 'in work' is good for people but individuals often disagree, preferring a pay-off, benefits and a life of leisure.

• Can you persuade them otherwise?
• Can you work with an OH department at work constructively if a patient is disinclined to co-operate?

Perception of risk by itself will not make him adopt 'risk-reducing' behaviours. He needs to believe that he has control over the risk and will then be more likely to comply with measures to lower his risk. You need therefore to communicate the level of risk, how the risk reduces if he behaves in a certain way ('reduction efficacy') and how he can be confident in reducing risk by (say) stopping smoking ('self-efficacy').

Supposing the occupational health nurse at work writes to you asking what behaviour, dietary and physical, you would like to see changed in the workplace, what would you say? Write down half a dozen bullet points and try them out on your colleagues. How realistic are they? Which are the most important?