Occupational and Environmental Health
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Occupational and Environmental Health

Author

Lindsay Davis, DO, MPH
Chair, EMRA Toxicology Committee
Central Michigan University

Faculty Reviewer

Jonathan Borak, MD
Clinical Professor
Yale School of Medicine

Special thanks to our 2nd edition writing team

Jared Marshall, MSIV
Benjamin Stoyak, DO, MPH, MBA
Chris M. Woodard, MSIII

INTRODUCTION

Description of the specialty
Occupational and Environmental Medicine (OEM) is a specialty in which physicians focus on the evaluation, treatment, and prevention of diseases related to workplace and environmental exposures. They work closely with and advise governmental and state agencies, organizations, and regulatory bodies. Many current environmental health concerns are byproducts of industrial activity, particularly toxic releases, air pollution, and other contaminants. Therefore, physicians interested in OEM should work toward an in-depth understanding of industrial health, as it is directly related to environmental and public health concerns.

History of the specialty/fellowship pathway
Occupational medicine first began in the 1700s, when Bernardino Ramazzini published about the diseases resulting from noxious gas and dust in the workplace and from improper posture of the body. The industrial revolution gave rise to medical inspectors in factories and physicians dedicated to taking care of patients harmed by industry. In 1914, focus on the importance of environmental and occupational exposure led the U.S. Public Health Service to create the Office of Industrial Hygiene and Sanitation. Then in the 1920s, Dr. Alice Hamilton — an assistant professor of industrial medicine at Harvard Medical School and the first woman to be on the faculty of Harvard University — pioneered the specialty as a division within public health and preventive medicine. By 1970, the National Institute for Occupational Safety and Health (NIOSH) and Occupational Safety and Health Administration (OSHA) were created. As a result, there are funds allocated for both the training and employment of physicians within OEM, resulting in numerous residencies and fellowships for this specialty across the country.

Why residents choose to follow this career path
Residents choose to follow this career path when they have an interest in caring for those affected by occupational and environmental hazards. This fellowship provides the resident with the tools to prevent these hazards from affecting the health of the population, the ability to treat those who suffered from exposure to such hazards, the investigative knowledge needed to identify the source of disease resulting from occupation and environment, the leadership skills to promote policy changes within the government, the educational skills to teach other physicians about the field, and the research skills to help improve the health of individuals and communities.

How do I know if this path is right for me?
Are you interested in treating patients with environmental exposure-related diseases? Are you interested in recognizing and finding solutions for both workplace and environmental hazards? Would you like to be involved in creating workplace and environmental health policy? Does research within OEM interest you? If so, this fellowship may be a good fit for you.

Career options after fellowship
After completing this fellowship, physicians may work in private practice, industry, government, military, community, or academia. They are typically engaged in clinical, leadership/administrative, research, and/or education roles.

Splitting time between departments
It would be unusual for a physician in OEM to split time between the emergency department and the office of the OEM specialist. However, if you have completed both an emergency medicine residency and this fellowship, you will find yourself a more suitable applicant for a job that allows you to practice in both fields. Fulfilling positions in these two, often separate, positions may be difficult; you will have to convince two different departments to hire you and decide on the split that you work in each, such as 50% in each, or 75% in one or the other. Be careful that you protect yourself from a circumstance such as back-to-back shifts overnight into the next day. You will also need to negotiate things such as vacation time, conference time, days off, benefits, etc. Having two certifications in two unique specialties makes you a valuable commodity for an institution. Remember this, and make sure to confidently sell your skills/training during your contract negotiation.

(Of note: Much OEM patient care addresses injury and acute conditions that often require emergent attention. This, in and of itself, shows the overlap that exists in ED and OEM practice. Interestingly, some very successful and prominent OEM physicians, including senior academics, also practiced emergency medicine.)

Academic vs. community positions
The decision between community, academic, or government positions depends on your individual career aspirations. Those who enjoy research and education tend to gravitate towards academia. Some people enjoy health policy and lean toward government careers. Others seek out jobs working for industry or private sectors.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Many organizations curate lists of OEM residency opportunities. The American College of Occupational and Environmental Medicine and Association of Occupational and Environmental Clinics offer up-to-date lists of opportunities and residency programs as they become available. Presently there are many programs, notably:

Differences between programs
You will notice that some of these programs are listed as residencies. This is because you do not need to complete a residency within emergency medicine to apply. You only need one year of residency to complete an OEM training program. Some of these programs specifically list on their website that they offer positions to those trained in emergency medicine, whereas others do not. Some programs also preferentially or only consider physicians who have completed a residency training program, whereas the majority of programs only require the completion of a PGY-1 year. Also, the focus and expectation to be involved in research during fellowship will vary per program.

Length of time required to complete fellowship
2 years

Skills acquired during fellowship
After fellowship, you will be prepared to participate in a multi-disciplinary approach to planning, implementing, managing, and evaluating programs and services for environmental health and worker health and safety. You will develop a broad clinical knowledge of the spectrum of disease that affects these patients. Finally, you will gain leadership, educator, and research training.

Typical rotations/curriculum
During most OEM fellowships you will be required to complete a Master’s in Public Health (MPH) or similar program, which typically takes 1 year to finish. The second year is usually 12 months of clinical time focused on public health-oriented administrative rotations. Example clinical rotations include large industries, occupational and subspecialty clinics, poison control centers, and public health agencies. You will likely participate in site visits to locations with occupational and/or environmentally suspected diseases. Research opportunities are offered by most institutions.

Board certification afterward?
Those who complete this training are eligible to obtain certification in occupational medicine as provided by the American Board of Preventive Medicine.

Average salary during fellowship
The average salary provided varies between institutions but will typically be based on the appropriate PGY level salary.

PREPARING TO APPLY

How competitive is the fellowship application process?
This is a moderately competitive residency/fellowship.

Requirements to apply
Minimum one year of residency in an ACGME-accredited program with a minimum of 11 months of direct patient care.

Research requirements
Research is not required but is highly suggested. If you do engage in research, it is much better to focus on one project and follow it to completion than to start but not finish many projects.

Suggested elective rotations to take during residency
Elective rotations to consider include poison control, toxicology service with focus on environmental toxins, “Work First” and other occupational health clinics, research months with focus on OEM topics, and public health agencies.

Suggestions on how to excel during these elective rotations
It goes without saying that you should arrive early and stay late during your rotations. Show your enthusiasm in the subject matter and motivation to learn by being as involved as possible. Continue to read and expand your knowledge base. Be a team player and look for physician mentors in OEM (and potentially future letter of recommendation writers) during these rotations. Treat every day as if it was an interview day and remain as professional as you can be.

Should I complete an away rotation?
If your program does not offer an away rotation within the realm of OEM then it would be worth considering an away elective. Arranging a rotation at an institution where you are considering a fellowship may be helpful as well.

What can I do to stand out from the crowd?
The ideal applicant is one whose application clearly displays commitment to the field of occupational and environmental health. Becoming chief resident can certainly help your application. Ideally, you should have some sort of activity in which you have a meaningful leadership role.

Should I join a hospital committee?
If your hospital offers a committee that is within the field of occupational and environmental medicine, then we highly recommend joining it. Actively pursue leadership positions within these committees.

Publications other than research
Publications other than research are also encouraged. Examples of such publications include blog posts, newsletter articles, magazine articles, and patient case publications. Creating a podcast episode is another consideration. Such publications are a great way to educate both yourself and the physician community about topics relevant to OEM.

How many recommendations should I get? Who should write these recommendations?
Most programs require a minimum of 3 letters of recommendations (and some programs may require 4). One of these must be either from your program director or your ED director. The others should be from physicians who know you well and can speak to your strengths as a fellowship candidate. Be sure to ask for a strong LOR from all your letter-writers; if they cannot provide a strong LOR, consider choosing a different letter-writer. LORs from physicians involved in the occupational and environmental health field are most ideal.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
You can absolutely still be competitive when applying after being an attending. The key is to use your time as an attending to continue to show your involvement and interest in occupational and environmental health and build your resume. Actively pursue leadership opportunities within your hospital system, and if possible, local OEM organizations. If you have no involvement in the field and then decide to apply after years of practice, it will be hard to convince a program that you are serious about this fellowship.

What if I’m a DO applicant?
Please note that most programs request USMLE scores in their application process.

What if I am an international applicant?
International applicants must have completed an ACGME accredited PGY-1 year and also must have a visa that is accepted by the institution. Please contact individual institutions for more details.

APPLICATION PROCESS

How many applications should I submit?
Apply to all programs you would seriously consider attending if offered a fellowship position.

How do I pick the right program for me?
Choose a program that will help you achieve your career goals. You want a program that believes strongly in you as an individual. Do you feel like you fit in at their program? Do the residents/fellows/faculty seem happy? Also, make sure the program is in a location where you wouldn’t mind living for 2 years. Finally, do not discount the opinions of family, especially in terms of program location.

Common mistakes during the application process
Common mistakes include the following: not submitting your application on the first day of application acceptance, not submitting a complete application, having LORs from physicians who do not know you well or do not 100% support you, or having an application that does not display a strong interest in OEM.

Application deadlines
Please note that some programs use ERAS and others have their own separate application process. Please refer to each program’s website for more information. Of note, for many programs you have to apply to both their fellowship and MPH program. Oct. 15 appears to be the most common application submission deadline, but again, please refer to each individual program for additional information.

Tips for writing your personal statement
The best personal statements read like a story that focuses on your interest in the field. The worst personal statements are ones that simply repeat your CV without providing the reader with any insight about your personality or your career goals. Is there a particular mentor or patient who sparked your interest in occupational and environmental medicine? If so, write about this. The reader should understand why you are passionate about this field, how your experiences have expanded that passion, and why they would benefit from giving you the position. What goals do you want to accomplish during fellowship, and in the years soon thereafter? It may be worth including your 5- and/or 10-year career goals.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
If you do not match into a fellowship position, take a critical look at your application and find the deficits that need to be corrected before you apply again. Consider asking one of the programs for specific feedback about why they did not choose you. You can also ask your program director or assistant program director to look over your application for deficiencies as well. Practice your interview skills and continue to seek out opportunities for involvement in this field to help strengthen your application. Consider applying only for a MPH and applying for the fellowship later. If all else fails, you may be able to build your niche within this field despite not completing a fellowship by attending conferences, additional coursework, and research.

INTERVIEW PROCESS

How do I stand out from the crowd?
During the interview, your goal is to be confident, pleasant, and engaging, with a clear vision about your future career in OEM. Be confident without sounding arrogant. Be courteous to everyone, and send thank-you notes to those who interviewed you.

What types of questions are typically asked?
Why are you interested in completing an OEM fellowship?

Why are you interested in completing this fellowship here?

What are your 5- and 10-year career goals?

Please elaborate on an activity or accomplishment listed in your CV.

What are your strengths and weaknesses?

How many interviews should I go on?
You should attend as many interviews as are offered (assuming that you only applied to places that you would seriously consider attending if offered a position).

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Rom W, Markowitz S. Environmental and Occupational Medicine. 4th Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
  • LaDou J, Harrison R. Lange Series: Current Diagnosis and Treatment Occupational and Environmental Medicine. New York, NY: McGraw-Hill Education; 2007.
  • Tarlo S, Cullinan P, Nemery B. Occupational and Environmental Lung Diseases. Online: John Wiley & Sons; 2010.

Important skills to practice while in residency to prepare for fellowship
Research skills, knowledge of core areas of preventive medicine, administrative and leadership skills, patient care of those suffering from occupational and environmental exposures, clinical educator tasks, and knowledge of epidemiology and biostatics.

Tips on how to succeed as a fellow
Success during fellowship starts with choosing a program that best suits you and is in a location that suits both you and your spouse. The happier you are with your program and your life outside the hospital, the more productive you will be during fellowship. Read daily and continually expand your knowledge base. Be reliable, take great care of patients, and be a team player. Take advantage of every opportunity fellowship offers, and consider the legacy that you would like to leave behind.

CONCLUSION

Additional resources

Journals

Journal of Public Health

The Annals of Occupational Hygiene

Occupational Medicine

Journal of Occupational and Environmental Medicine

Electronic resources

Occupation Medicine Podcast

Webinar

Online lectures

National organizations

American Academy of Environmental Medicine

American College of Occupational and Environmental Medicine

The Society of Occupational Medicine

American Board of Preventive Medicine

American Osteopathic Board of Preventive Medicine

Conferences

How to find a mentor
Currently we are unaware of a website or organization that helps pair interested residents with faculty in the field. However, we encourage you to use elective time to rotate through relevant operations and environment medicine rotations and strive to make connections with future mentors. The OSHA website may also be a valuable resource to help connect with local clinicians and leaders in this field.

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