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Can You Trust Your Doctor?

Medico Legal

by David Asker-Browne - Chartered Occupational Hygienist

I am minded to tell you a story about a respected respiratory physician who got himself – and me – into deep water.

The case involves a man who had worked as a saw sharpener for more than 20 years. For the last 7 years of employment he reported breathing problems. His job was to sharpen saws, the teeth of which had been coated with tungsten carbide to give them resistance to wear. The blob on the end of a masonry drill is tungsten carbide. Initially his GP diagnosed asthma and gave him an inhaler, but over the coming years the problem persisted and he was referred to the local hospital respiratory department Eventually the saw sharpener lodged a claim against his employer for causing his asthma.

At this point, the specialist chest physician was appointed as the Claimant’s expert, since he headed up the respiratory department concerned. After a lot of toing and froing, he came up with a report that attributed the Claimant’s complaint to ‘cough variant asthma’.

The gist of my occupational hygiene report was that Hard Metal Disease had been associated with saw sharpening for more than 60 years, and that it was widely documented. I referred in particular to Occupational Lung Disorders (2nd Ed) by W. Raymond Parkes. In a nutshell, it starts with asthma. If the worker is removed from the tungsten carbide exposure at an early stage it will abate. However, if exposure persists it will eventually develop into lung cancer via an intermediate stage.

My report to the Court suggested that the Medical Expert should review his evidence and consider a diagnosis of Hard Metal Disease. At this point, the Judge threw out my report, declaring that not being a physician I could not disagree with one, nor make a diagnosis. My report was not admitted into evidence. However, the Medical Expert must have seen a copy, since shortly afterwards he changed his diagnosis to Hard Metal Disease. You could say that I was miffed!

To my mind, the Medical Expert was out of his depth. He had no training or qualifications in Occupational Medicine, and was clearly unaware of a respiratory condition that has been a classic occupational health example since the end of World War II. On the other hand, I felt well within my competence since the subject was part of my occupational hygiene training, and I had advised a pan-European tungsten carbide coating company for more than 10 years.

So what can we learn from this? Were the Instructing Solicitors at fault for appointing a Medical Expert with no training or experience in work related disease? Was the Medical Expert himself at fault, for not admitting that this case was outside his competence? Or was the Judge at fault by being pig-headed?

We could say that the problem goes back to the employer, for not doing his risk assessment properly. But there’s nothing unusual in this. Most cases of work related ill-health that come to my attention have inadequate risk assessments. This is no surprise, since employers who get the risk assessment right don’t finish up in court.

Of course, the employer will say he did his best, and if that’s not good enough he has an insurer to fall back on. Are insurers doing enough to ensure that employers fulfill their health and safety obligations? Sadly the answer is “No”. Their view seems to be that of the betting shop – as long as the odds are covered, they’re OK. Admittedly, some of them do advise their clients on risk reduction, but is this self-interest at work? Do insurers check to see if risk assessments are adequate?

As with most occupationally induced ill-health, once you have got it, it’s too late. There is no cure for noise induced hearing loss, or for silicosis or respiratory sensitisation. Vibration induced white finger is for life. The answer has to lie in prevention. At the moment the Health and Safety Executive (HSE) support the view that 14,000 people every year die with a work related lung condition. Work causes 8,000 new cases of cancer or COPD every year.

In bygone days, it wasn’t doctors that cured cholera or diphtheria. It was engineers, who brought about drains and improved sanitation and water supplies. By the same token, it won’t be doctors that bring about a reduction in work related death and disease. It will be employers who understand workplace contaminants and their toxicology, and how to get them under control. They can learn this from professional occupational hygienists but there is a woeful ignorance of our capabilities. It would be prudent for litigating solicitors to seek the opinion of an occupational hygienist early on in a claim for work related ill-health. This would enable the solicitor to receive help on the validity of such a claim and also with the selection of potential expert assistance. In the case of a medical input to a case, complete with a prognosis of future health, I would normally recommend membership of the Faculty of Occupational Medicine as a prerequisite. Occupational physicians and occupational hygienists have a close understanding of the synergy between our two professions.

The spectrum of occupational ill-health is changing as we move towards a knowledge based society. The pneumoconioses from coal mining are diminishing as the industry shrinks and automation improves. As the heavy industries decline, the incidence of noise induced hearing loss has halved in the last 10 years, as have cases of vibration white finger. But what is waiting in the wings? We are already seeing hand and neck problems in young people, from the use if their mobile phones. Will we see premature deafness from music exposures via earphones? We are already watching the world of nanotechnology, where there is much yet to understand and little epidemiology. Have we reached the point where lifestyle is more of a problem than workplace hazards? Alcohol, processed meats, obesity and poverty are all getting a share of the blame today. Almost 300,000 new cancer diagnoses were made in the UK in 2015, which is a rise of 22% from 2005, according to the Office for National Statistics. Is there a relationship here between the rise in cancer diagnoses and the growth in diesel powered vehicles? The evidence supporting diesel exhaust emissions as a cause of lung cancer is very weak. However, diesel fume is a source of very fine particulate matter – less than 10 microns in diameter. The International Agency for Research on Cancer and the World Health Organisation designate airborne particulates as carcinogens. In 2013, a study involving 312,944 people in nine European countries revealed that there was no safe level of particulates and that for every increase of 10 μg/m3 in PM10, the lung cancer rate rose 22%. The smaller PM2.5 were particularly potent, with a 36% increase in lung cancer per 10 μg/m3 exposure as it can penetrate deeper into the lungs.

Occupational hygienists are employed throughout the English speaking world. The Occupational Hygiene Training Association is gaining traction and influencing the global training of occupational hygienists. This is under the auspices of the International Occupational Hygiene Association who work to ensure that best practice is followed by all practitioners, wherever they may be.

But we are far from being out of trouble. According to the U.S. Geological Survey, more than a million tons of asbestos were mined in Russia in 2013. Much goes to India and China, where it is in high demand as a building material. So the scale of asbestos related disease in the UK is nowhere near what we can expect to see in Asia in the decades ahead. This is of considerable interest to tourists and those who elect to work abroad. The global effort to abate asbestos exposure is by no means successful, and in some countries it may be getting worse. Other concerns include malaria, where the World Health Organisation has been on an active prevention campaign for many years. Malaria remains an acute public health problem, particularly in sub-Saharan Africa. According to WHO, there were 212 million new cases of malaria and 429 000 deaths worldwide in 2015.

So whilst work induced ill health concerns us in the wealthy western nations, they look less significant when compared to international public health issues around asbestos, malaria and delivering affordable health care.