Occupational history: A neglected component of history taking.

Dear Sir,

Effective history taking has long been identified as a core discipline in treating patients that seek health care. Spending more time compiling a good patient history has been documented to provide the most benefit, when compared to longer physical examinations and expensive laboratory diagnostic methods.[1] Collecting an inaccurate or incomplete history can affect initial therapy and all subsequent decisions for treatment. Therefore, it is essential that primary care physicians ensure that neither the patient nor the health system is burdened by the perils of deficient history taking.[2] Various studies have also concluded the need for more rigorous training and assessment at medical schools to aid better history taking.[34] Newer methods of history taking such as the use of automated history takers, structured questionnaires, and virtual patients for training medical students have emerged with promising application.[567] Yet, even with such technological advances, the patient-doctor bond has remained the most integral part of effective history taking.

The comprehensive adult history is known to elicit information on present illness, past medical and surgical history, family history, and a personal or social history. A good personal and social history must by nature also contain information on occupation and a job history.[8] The International Labour Organization estimates about 270 million fatal and nonfatal work-related accidents and 2 million work-related fatalities from accidents and disease every year the world over.[9] An increase in world trade and the use of newer technology has further exacerbated occupational accidents and disease with developing countries facing the brunt due to lacking or poor enforcement of formal occupational safety and health inspection services.[10] Further, poor reporting of occupational accidents and disease ensures many such incidents go untreated or wrongly treated, thus further underscoring the need for compulsory occupational history taking. Traditionally, the link between occupation and disease has been difficult to establish, but provided a more comprehensive occupational history taking methodology, it can lead to better diagnosis of disease with occupational origins.[11]

Taking an occupational history is known to provide benefits such as: Establishing a diagnosis when there is a suspected occupational link or causation, indicating appropriate treatment and management of the condition, initiating claims for compensation if there is a confirmed occupational exposure, identifying hazards at the workplace that may be eliminated or controlled and initiating future research to better understand diseases which have multifactorial or obscure causes.[12] Most often, work-related diseases are underdiagnosed due to deficient occupational histories, with many illnesses of known occupational causes being ascribed to other causes or conditions.[13] Furthermore, severe sentinel health events and those involving a large number of exposed individuals may be reported to the concerned health departments or regulatory agencies as a useful control measure.[14]

Exposure history forms have been developed by the Agency of Toxic substances and Disease Registry, which are very detailed and known to include most aspects of exposure to toxic chemicals in and around the home and at the workplace.[15] Occupational health risk assessment questionnaires have also been piloted among primary care physicians with promising potential for application.[16] The case for adding occupational aspects such as work history, past occupational history, and environmental history to a standard history form was made as early as the 1980s.[17] It is, therefore, alarming that even with such a concerted pitch for routine occupational and environmental history taking; it still has not found a way into the mainstream. In a study conducted among physicians in a medical facility in Turkey by Cimrin et al.,[13] it was reported that 43.9% (29/69) physicians did not take an occupational history at all, with only 22.7% (15/69) taking a detailed occupational history from all patients. Routine taking of occupational history is believed to enhance the physician's knowledge of occupational medicine and the ability to practice preventive medicine and intervene in the interest of the health of the patient.[12] Logistic barriers such as time, effort, and cost have been cited as reasons for the failure to effectively incorporate environmental history taking during regular clinical consultations.[18] The teaching of occupational medicine during both undergraduate and resident training is often lacking and limited.[13] Teaching, especially at the undergraduate stage is known to be the best time to expound the relevance of occupational health to physicians in training.[19] The benefits of Continuing medical education using e-learning in an occupational health care setting has been documented in a study among elderly physicians and needs to be explored for training undergraduate and graduate medical students as well.[20] The need for a two-pronged strategy to improve both occupational health training and education to students, along with encouraging occupational history taking as a part of standard history taking among primary care physicians has for long been realized, but must be a health care mandate for this century.