How to Define the Content of a Job-Specific Worker's Health Surveillance for Hospital Physicians?

BACKGROUND: A job-specific Worker's Health Surveillance (WHS) for hospital physicians is a preventive occupational health strategy aiming at early detection of their diminished work-related health in order to improve or maintain physician's health and quality of care. This study addresses what steps should be taken to determine the content of a job-specific WHS for hospital physicians and outlines that content.
METHODS: Based on four questions, decision trees were developed for physical and psychological job demands and for biological, chemical, and physical exposures to decide whether or not to include work-related health effects related to occupational exposures or aspects of health reflecting insufficient job requirements. Information was gathered locally through self-reporting and systematic observations at the workplace and from evidence in international publications.
RESULTS: Information from the decision trees on the prevalence and impact of the health- or work-functioning effect led to inclusion of occupational exposures (e.g., biological agents, emotionally demanding situations), job requirements (e.g., sufficient vision, judging ability), or health effects (e.g., depressive symptoms, neck complaints). Additionally, following the Dutch guideline for occupational physicians and based on specific job demands, screening for cardiovascular diseases, work ability, drug use, and alcohol consumption was included. Targeted interventions were selected when a health or work functioning problem existed and were chosen based on evidence for effectiveness.
CONCLUSION: The process of developing a job-specific WHS for hospital physicians was described and the content presented, which might serve as an example for other jobs. Before implementation, it must first be tested for feasibility and acceptability.

Introduction

Hospital physicians are exposed to several occupational risk factors that can lead to work-related health complaints. Occupational exposure to biological or chemical substances [1], [2], to physical job demands like adopting uncomfortable and exhausting working postures [3], or to psychological job demands such as experiencing violence [4], or the death of a patient [5] are common in the work of hospital physicians. Work-related health complaints that have previously been associated with occupational exposures in the work of hospital physicians are, among others, complaints in the neck [6], [7] and lower back [3], [7] region and symptoms of stress [8] and burnout [8], [9]. A reduced health status of hospital physicians in relation to work is associated with reduced work ability [8], threatening quality of care, and potentially putting patients' safety at risk [10]. Focusing on prevention or early detection of diminished health might not only increase the well-being of hospital physicians, but could also maintain or improve quality of care and secure patients' safety better.

One of several preventive occupational health strategies that can be offered to employees to maintain or improve work-related health is a periodic Workers' Health Surveillance (WHS) [11]. In the Netherlands, an employer is required by legislation to periodically offer a WHS to its employees. In a collective agreement the employer and a labor-union can make additional agreements on the frequency and timing of offering a WHS. While the employer is responsible for financing the WHS, an independent occupational health service is primarily responsible for the content and organization of the WHS, which also includes keeping records of the data. Participation of the employee is voluntary.

The central purpose of the WHS targets prevention of occupational and work-related diseases and injuries [12]. Internationally, WHS aims at detecting unhealthy occupational exposures and/or the prevention or early detection of health complaints that can be related to occupational risk factors [12]. In the Netherlands, WHS encompasses inviting employees to perform medical examinations, followed by an individual consultation with the occupational physician where individual feedback is followed by advice on targeted interventions when applicable [13]. Follow-up consultations are planned with the occupational physician to register to what extent the advice or intervention is followed and/or the work-related health or work-functioning of the employee has improved. On a group level, results of the medical examinations can be reported to the employer together with advice or recommendations on an organizational level.

In the case of work consisting of specific job demands, interventions to prevent work-related health problems might be directed towards increasing personal abilities to deal with these job demands. Specific job demands are defined as job demands with a risk of work-related health problems or diminished safety that cannot be reduced by adjusting working procedures and that exceed exposure safety levels or average human capacity to meet such demands on a daily basis [14]. To that end, by taking a more health-centered approach, the WHS monitors and promotes an individual's health in relation to work. It focuses particularly on the question of whether worker's health is sufficient to meet the demands of the job [13].

These purposes of the WHS imply a job-specific approach rather than a general one. Following the International Labor Organization (ILO) guidelines, WHS should take into account the occupational hazards in the workplace and the health requirements of the work, to make sure the surveillance of worker's health is appropriate to the occupational risks of the job [12]. The ILO considers investigating occupational risk factors as part of the WHS; in the Netherlands this is regulated differently and is done prior to the WHS in a so-called structured risk assessment and evaluation. This job-specific approach of a WHS is necessary because in the case of work-related health complaints, attention should be directed at finding the exact mismatch between job demands and the individual's abilities to meet these demands [15]. Furthermore, not only does a job-specific approach of a WHS allow for interventions that best fit with the occupation of interest—therefore increasing the likelihood of effective interventions to increase work functioning—but workers should also be protected from an abundance of screening tests and assessments that do not forecast how well they perform their job [16].

In conclusion, to maintain and improve the work-related health of hospital physicians, which will positively affect the quality of care and help secure patient safety, a job-specific WHS for hospital physicians should be developed. Because we have observed that a culture is lacking in Dutch hospitals of focusing on preventing work-related health problems, we developed a job-specific WHS for hospital physicians. In this study, the questions of what steps should be taken to arrive at a job-specific WHS and what the content of a job-specific WHS for hospital physicians should be are addressed.

Materials and methods

To determine the content of the job-specific WHS for hospital physicians, a decision tree was developed based on answers to four questions (Fig. 1). Subdecision trees were developed for the different type of job demands and occupational exposures. Irrespective of the type of demands or occupational exposures, all decision trees were designed to establish whether or not to include work-related health effects known to be related to job demands, or whether or not to include aspects of health that reflect insufficient job requirements of the individual hospital physician to meet the demands of the job.

Fig. 1

Decision tree for occupational exposures and job demands with stepwise question checking. WHS, Worker's Health Surveillance.

Before question 1 of the decision tree could be answered (Fig. 1), occupational exposures and job demands in the work of hospital physicians needed to be identified. Information regarding physical job demands was gathered in two ways: through self-reporting or direct observations of hospital physicians of one Academic Medical Center in the Netherlands [8], [17]. Direct observations, to gather data in terms of duration, frequency, and intensity, and data regarding mean and peak energetic load, were performed during the work of 126 hospital physicians [17], [3]. To account for the differences in tasks and activities between several medical specialties, the physical job demands were reported, when possible, for three clusters of medical specialties. The clusters of medical specialties were: (1) observational medical specialties (e.g., Internal Medicine); (2) supportive (e.g., Radiology), and (3) surgical (e.g., General Surgery). Psychological job demands and biological exposures were obtained from evidence-based information from international studies, and locally through self-reporting [8]. Insight into chemical and physical exposure was obtained through international evidence [17]. Once the occupational physical exposures and job demands were identified, they were compared with the guidelines of occupational exposures and job demands, e.g., with Dutch guidelines of occupational exposures and job demands (Fig. 1, question 1) [18]. When the occupational physical exposures and job demands did not exceed these guidelines, but a considerable proportion of hospital physicians felt bothered by the physical job demand (Fig. 1, question 1B), it was still considered a potential threat to good health and work-functioning. Question 1PsEx served to gather information regarding the prevalence of emotionally demanding situations, thereby contributing to the evidence base of the WHS. A cut-off of 10% was established beforehand, because this cut-off was used in the final process of deciding on inclusion or exclusion in the WHS. Data that were needed to answer questions 1B and 1PsEx (Fig. 1) of the decision tree were obtained locally through self-reporting by 900 hospital physicians and medical residents and through evidence-based information from international literature [8], [17].

Regarding the second and third questions of the decision tree (Fig. 1), identifying health- and work-functioning problems that could either be related to the occupational exposures or reflect a lack of resources on the part of the hospital physicians to cope with the job demands, and the prevalence of these health effects among hospital physicians was evaluated by looking for international evidence, and locally through self-reporting by 900 hospital physicians and medical residents [8], [17]. With respect to question three, our expert group of researchers decided to label the prevalence of health effects as ‘high’ when exceeding a prevalence rate of 10% or when this was higher among hospital physicians compared with the general population.

To answer the fourth research question (Fig. 1), our expert group of researchers identified three aspects to decide upon the impact of the specific health- or work functioning problem: (1) whether it bothered the individual worker; (2) whether it led to restrictions in daily work functioning; and (3) whether it posed a potential risk for others. When hardly bothering the individual, hardly restricting daily work function and posing no risk for others, the impact was considered small. The impact was labeled as medium when the health effect was bothering the individual in some way, but was not restrictive in daily work functioning or posing a risk for others. When a health problem was significantly restrictive in daily work functioning and/or formed a potential risk for others, the impact was considered high.

In the result section, the main focus is on clarifying the content of the WHS, which starts with describing which aspects of the job demands or job requirements should be included in the job-specific WHS based on the results of our decision trees. Subsequently, the results focus on how these aspects were measured in the WHS, how a signal of occupational exposures exceeding health- or safety guidelines or of a reduced health status was detected, and what interventions the occupational physicians could perform in the case of such a signal.

Results

First of all, the questions of the decision trees were answered for the different types of occupational exposures, job demands, and job requirements. To finally decide whether or not to include the occupational exposure, job requirement or health effect in the job-specific WHS, a priori decision rules were followed that used the information resulting from the questions of the decision trees. For both the physical job demands and the biological, chemical, and physical exposures, screening of the health- or work-functioning problems was included when: (1) the prevalence of the health- or work functioning-effect was high and the impact medium or big; or (2) the prevalence of the health- or work functioning-effect was low or unknown, but the impact big. Regarding the psychological job demands, other rationales were formed. Screening of the health effects was included in the WHS in one of the following cases: (1) prevalence of the emotionally demanding situation was high and the impact medium or big; (2) accidental exposure to the emotionally demanding situation is sufficient to lead to health- or work-functioning problems and the impact of these problems is medium or big; or (3) prevalence of the emotionally demanding situation is low, but the impact is considered big. Table 1 lists some examples of how these decision trees and decision rules were followed for different occupational exposures, job demands, or job requirements.

Table 1

Steps taken in following decision trees: examples of different occupational exposures, job demands, and job requirements

	Question 1	Question 1B	Question 2	Question 3(%)	Question 4	Inclusion WHS?
Physical job demands
VDU work	Yes		Complaints in:
Neck	High (31)	Medium/high	Yes
Shoulder	High (17)
Wrist/Hand	High (13)
Fine motor movements(surgical specialisms)	Yes		Complaints in:
Neck	High (31)	Medium/high	Yes
Shoulder	High (17)
Wrist/Hand	High (13)
Physical job requirements
Sufficient vision	Yes		Work-functioning problems due to reduced sight		High	Yes
Biological/chemical exposure
Biological agents	Yes		Hepatitis BHIVDiarrhea, etc.	Unknown	High	Yes
Halothane in OR	Yes		Irritation of skin, eyes and/or respiratory tract	Unknown	High	Yes
Benzene	No	Unknown				No
Psychological job demands
Verbal aggression by patients	High prevalence(20%)		Depressive symptoms	High (29)	High	Yes
Anxiety symptoms	High (24)
Death of a patient(once or more during the last 4 wk)	High prevalence(26%)		Stress	High (15)	High	Yes
Burnout	Low (6)

OR, operation room; VDU, visual display unit; WHS, Worker's Health Surveillance.

In addition to the inclusion of job demands, occupational exposures, and job requirements resulting from the decision tree, specific or safety job requirements were included in the WHS, given the existing Dutch guidelines for occupational physicians and the guide on specific job demands [18]. For example, the work of hospital physicians requires them to maintain a heightened state of alertness 24/7. In acute complex situations they need to be able to act quickly and adequately. Screening in the WHS on aspects that could negatively affect the ability to maintain this heightened state of alertness was, therefore, found to be feasible and relevant. These aspects include the chosen content of screening for psychological health complaints (e.g., depressive symptoms), drug use, and alcohol consumption. Furthermore, with the aim of maintaining and promoting the health status of hospital physicians in relation to their work, monitoring risk factors for developing cardiovascular diseases was found relevant to be included in the WHS as well. Finally, to detect general problems that might affect the work ability of the hospital physicians, the self-reported Work Ability Index [19] was included, as well as enquiring after all other unaddressed health problems that might affect their work ability. An overview of the WHS protocol is shown in Table 2.

Table 2

Topic list and measurement protocol of the job-specific Worker’s Health Surveillance (WHS) for hospital physicians

	Aspect of job requirement or job demand to be included in WHS	Instrument used in WHS(Written signaling question/validated screener/validated test/direct measurement)	Outcome measures	Signal when:
Physical job requirements
Musculoskeletal system		Signaling question
Neck flexion and rotation	Neck complaints	“Did you experience recurrent  and/or prolonged complaints  in [body region] during the last 6 mo?”	yes/no	Outcome is “yes”
Standing	Lower back complaints
Sitting	Shoulder complaints
Computer work	Hand/wrist complaints
Fine motor skills		If yes, do you feel impaired in  executing your work because of this  complaint? (yes/no)	yes/no	Outcome is “yes”
Sufficient vision	Problems with vision	Signaling question [21], [20]
“Do you have trouble reading during  your work?”	yes/no
Vision test [20], [21]		Outcome is “yes” or score vision test < 0.8
Landolt C rings, distance 40 cm and 60 cm (both eyes together; if job demand includes  using only one eye, also eyes separately)	Eyes togetherLeft eyeRight eye
Sufficient hearing	Problems with hearing	Signaling question
“Do you have trouble hearing during  your work?”	yes/no	Outcome is “yes” or number of errors whisper test per ear > 4
Hearing test [22]
Whisper test – 6 combinations per ear	No. of errors per ear (range, 0–6)
Physical job demands
Exposure of skin to solid or  liquid substances	Work–related skin complaints (e.g.,. contact dermatitis)	Signaling question
“Do you currently experience skin complaints  on arms or hands?”	yes/no	Outcome is “yes”
Risk of infectious diseases		Signaling question
	Experiencing bite- or needle stick-accident	“Have you recently (during the last four wk)  experienced a bite- or needle stick-accident?”	yes/no	Outcome is “yes”
	Exposure to body material	“Have you recently (during the last four wk)  been exposed to body material of patients?”	yes/no	Outcome is “yes”
	Presence of infectious diseases that pose a risk to others	“Do you currently have an infectious disease?”	yes/no	Outcome is “yes”
Exposure of respiratory tracts  or lungs to dust, smoke, gas,  or vapor	Work-related complaints of lungs or respiratory tract (e.g., COPD or asthma)	Signaling question
“Do you currently experience complaints  with your respiratory tracts or lungs?”	yes/no	Outcome is “yes”
Psychological job demands
Emotionally demanding situations		Signaling question
	Recently experienced aggression	“Did you recently experience…..
		…. aggression from a patient towards  yourself or a colleague?	yes/no	Outcome is “yes”
		.... aggression from a colleague or  supervisor towards yourself?”	yes/no	Outcome is “yes”
	Recently experienced trauma	“Did you recently experience…..	yes/no	Outcome is “yes”
		.... a severe traumatic incident?”
Psychological job requirement
Alertness and judging  ability	PTSD	Screener: Dutch Impact of Event Scale (SVL) [24], [23]	Score 0–75	Score ≥ 20
		Signaling question
	Drug use	“Do you use drugs?”(yes/no)	yes/no	Outcome signaling question is “yes”
		If yes, which?
		- Painkillers	yes/no	Outcome signaling question is “yes”
		- Tranquilizers
		- Sleeping aids
		- Other…
	Sleepiness	Screener: Epworth Sleepiness Scale [25]	Score 0–24	Score ≥ 10
	Alcohol consumption	Screener: AUDIT–C [26]	Score 0–12	Men: score ≥ 5
				Women: ≥ 4
	Depressive symptoms	Screener: GHQ–12 [27]	Score 0–12	Score ≥ 4
	Anxiety symptoms
	Stress symptoms
	Work-related fatigue	Screener: Need for Recovery after work scale [29], [30], [28]	Score 0–11	Score > 5
Work ability
	Current self-reported work ability	Screener: Work Ability Index – first item[score 0 (lowest ever) – 10 (highest ever)] [19], [31]	Score 0–10	Score ≤ 5
	Other prevalent health effects	Signaling question
		“Are there any health effects related  to your work that have not been asked  about yet, but that you would  like to discuss?”	yes/no	Outcome is “yes”
Risk factors cardiovascular diseases				Points for summing Dutch CVD risk profile
Risk profile		Signaling question		Male	Female
		“Does/did your father, mother, brother or  sister have….
	Prevalence of diabetes in family	…diabetes type 2?”	yes/no	Yes: 4	Yes: 3
	Prevalence of cardiovascular diseases in family	…have a cardiovascular disease  before age 65?”	yes/no	Yes: 1	Yes: 4
	Smoking	“Do you smoke?”	yes/no	Yes: 9	Yes: 9
	Waist circumference	Measurement	cm's	≥ 94 cm: 3	80–88 cm: 2
					≥ 88 cm: 6
	BMI	Measurement
		BMI = Weight/(Length × length)	Weight (kg), Length (m), BMI	25 – < 30: 4	25 – < 30: 4
				≥ 30: 12	≥ 30: 7
				Male	Female
	Age	Written question	Age (y)	< 45: 0	<45: 0
				45–49: 13	45–49: 10
				50–54: 17	50–54: 16
				≥ 55: 22	≥ 55: 23
				Total points < 30	Total points < 35
				with risk factor  OR total points  ≥ 30	with risk factor OR total points  ≥35
	Systolic and diastolic blood pressure	Measurement	Systolic blood pressure	≥ 140 mmHg
		Digital blood pressure reading (3 times) [32]	Diastolic blood pressure	≥ 90 mmHg

AUDIT-C, Alcohol Use Disorders Identification Test-Consumption; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; GHQ, General Health Questionnaire; PTSD, post-traumatic stress disorder.

After the job-specific demands, exposures and health- or work-functioning problems were selected that needed to be included in the WHS and targeted interventions were selected when a health- or work functioning problem existed. These interventions were chosen on their evidence for effectiveness and could be targeted at increasing the personal abilities or capacities of the individual hospital physician to cope with the job demands, or they could consist of (ergonomic) measures or medication or act on the individual organization of work interaction to reduce the occupational exposures and/or the resulting health- or work-functioning problems. The interventions were mainly based on existing national and international guidelines, e.g., guidelines of the Netherlands Society of Occupational Medicine (NVAB). An overview of the interventions proposed for each possible signal is shown in Table 3.

Table 3

Interventions for the occupational physician based on the results of the screening questionnaire and physical measurements

Physical job requirements
	Outcome	Intervention choice based on:
		Personal abilities/capacity	Measures/medication	Individual–work interaction
Musculoskeletal system
Lower back complaints	Signaling question “yes”, no impairment during workSignaling question “yes” and impairment during work	□ Discuss relevant tasks and activities within medical specialty of employee □ Inquire about nature, origin and development of current complaints and possible impairments [33] □ Consider referral to general practitioner or specialized consultant □ If work-related complaints, arrange for occupational disease notification □ In the case of reduced personal capacity, advise specific exercises to increase personal capacity [33] □ Follow up within 6 wk		□ Discuss task, activities and work–rest schedule □ In the case of impairments in work, advise to discuss outcome with manager
Neck, shoulder or hand/wrist complaints	Signaling question “yes”, no impairment during workSignaling question “yes” and impairment during work	□ Discuss relevant tasks and activities within medical specialty of employee □ Inquire about nature, origin and development of current complaints and possible impairments [34] □ In the case of shoulder- or hand/wrist-complaints due to excessive computer use: advise micro-breaks [35] □ In the case of complaints due to other tasks: discuss impairments in work and discuss possibilities of adjustments in organization of work and work environment [34] □ If work-related complaints, arrange for occupational disease notification □ Follow up within 6 wk	□ In the case of computer work: consider advising support for hand/wrist [35] □ In the case of complaints due to use of mouse: advise switching arms or advise alternative mouse [35] □ In the case of mainly sitting work at workplace, discuss workplace investigation by ergonomist [35] □ In the case of noncomputer related complaints: discuss impairments in work and investigate possible ergonomic interventions	□ Discuss task, activities and work–rest schedule □ In the case of impairments in work, advise to discuss outcome with manager
Sufficient vision	Signaling question “yes” or vision test < 0.8	□ If tasks performed with 1 eye: measure eyes separately □ If reduced vision for 60 cm, consider advising screen glasses □ Refer to optician □ Follow up within 4 wk		□ In the case of impairments in work, advise to discuss outcome with manager
Sufficient hearing	Signaling question “yes” or >4 errors for 1 ear	□ Discuss impairments during meetings or other activities □ Make tone audiogram or perform test with computer of audiological center (silence required) □ Follow up within 4 wk	□ Advise to get hearing aid □ Refer to ENT doctor or audiologist if results suggest this □ When program for hearing protection seems applicable: use guideline for Preventive Occupational Hearing reduction [36]	□ In the case of impairments in work, advise to discuss outcome with manager and colleagues □ Discuss possible sources of exposure
Physical exposures
Exposure of skin to solid or liquid substances	Signaling question “yes”	□ Inquire about current complaints and impairments □ Discuss possible causes □ Consider specialized interventions □ If work-related complaints, arrange for occupational disease notification and use the registration guideline “Occupational contact dermatoses” [37] □ In the case of contact eczema: investigate reduction of exposure to skin irritating factors, advise skin protection, skin cleaning and skin moisturizing [38] □ Follow up within 4 wk	□ Advise personal protection resources	□ Explore possibilities of reducing exposure □ In the case of impairments in work, advise employee to discuss outcome with manager (and perhaps colleagues who could temporarily take over tasks and activities)
Risk of infectious diseases	Signaling question “yes”	□ Strategy to carry out is dependent on infectious disease, use hospital-specific guideline “Hospital workers and infectious diseases” □ Discuss influence on work functioning		□ In the case of impairments in work, advise to discuss outcome with manager
Needle stick- or bite-accident	One or both signaling question “yes”	□ Discuss whether “PEP protocol” for needle stick-, bite- or sex-accidents was followed, inclusive of testing. When necessary, advise additional actions	□ When necessary, prescribe suitable medication
Exposure of respiratory tracts or lungs to dust, smoke, gas, or vapor	Signaling question “yes”	□ Check current complaints and subsequent impairments and investigate work-relatedness □ If work-related complaints, arrange for occupational disease notification □ Consider specialized interventions □ In the case of regular or chronic exposure to dust, smoke and vapor (smoking included): consider additional research for early diagnosis of COPD [39] □ In the case of COPD, choose possible interventions: stop smoking, adjustment of work/working schedule, reduced inhaling exposure, lung recovery [39] □ Decide whether it is a case of asthma: does the employee experience complaints of respiratory tracts or lungs in combination with dyspnea, wheezing on the chest and/or coughing, and complaints-free periods, signs of allergy cause, eczema, atopic, or asthma in anamnesis? In that case, it could be asthma. Then apply the steps from the asthma and COPD guideline [39] □ Follow up within 4 wk	□ Consider resources or inhaler	□ Explore possibilities of reducing exposure □ In the case of impairments in work, advise employee to discuss outcome with manager
Psychological exposures
Emotionally demanding situations
Traumatic experience	Signaling question on traumatic experience “yes”	□ Check the score on the Impact of Event Scale (see below) □ Discuss the item and consider advising the module “Resilience” on www.ephysicianhealth.com [40]
Aggression	“Yes” on one or both signaling questions on experienced aggression in work	□ When related psychological complaints are also present, consider arranging for occupational disease notification □ In the case of work-related aggression, refer to www.ephysicianhealth.com [40], module “Disruptive behavior” or module “Resilience” □ Inquire whether appropriate care was delivered right after the incident □ Consider giving the employee “Aggression composure and handling” or “Aggression and Violence, relief and after care” brochures □ Consider training and counseling		□ In the case of impairments in work, advise employee to discuss outcome with manager
Individual's psychological resources
Alertness and judging ability
	Score Impact of Event Scale [23]:20–25 and Score > 25	□ If work-related complaints, arrange for occupational disease notification □ Consider advising to use www.ephysicianhealth.com [40] and follow the “Resilience” module to reduce general stress complaints. Score 20–25□ Take note of the experienced trauma □ Discuss whether a one-time coaching or counseling session is desired □ Follow up within 4 wk Score > 25□ Discuss whether coaching or counseling is desired □ In the case of severe PTSD, advise therapy (cognitive-behavioral therapy, EMDR or Imaginary Exposure) □ In the case of severe PTSD, check for depression □ Make a follow-up appointment	□ If accompanied by depressive complaints, discuss use of drugs (see depression guideline NVAB) [41]	□ In the case of impairments in work, advise employee to discuss outcome with manager
Drug use	Signaling question “yes”	□ Discuss current drug use and potential influence on work functioning □ Consider advising www.ephysicianhealth.com [40] and the use of “Substance use” module □ In the case of addiction, refer to specialized clinic □ Arrange for follow-up appointment by phone within 6 wk
Sleepiness	Score Epworth Sleepiness Scale [25]≥ 10	Score 10–15		Score 10-15
		□ Discuss situational causes		□ Discuss temporary adjustments in work
		Score > 15	Score > 15	Score > 15
		□ Consider specialized consult (sleeping expert) and arrange for follow-up appointment	□ Consider prescribing drugs	□ In the case of impairments in work, advise employee to discuss outcome with manager and advise dayshifts temporarily
Alcohol consumption	AUDIT-C [26] score:Male ≥ 5Female ≥ 4	□ Discuss outcome in relation to health risks and patient safety □ Consider advising the “Substance use” module on www.ephysicianhealth.com [40] □ Consider advising autonomous intake reduction by using the free online course “Drinking less” [42] □ In the case of drinking abuse or high dependency: refer to general practitioner who can make use of the “Obstacles in the use of alcohol”(2009) guideline [43] □ In the case of addiction, refer to specialized clinic □ Arrange for follow-up appointment by phone within 6 wk
Depressive, anxiety and/or stress  symptoms	Score GHQ-12 [27]:≥ 4	□ If work-related complaints, arrange for occupational disease notification □ Consider to advise using www.ephysicianhealth.com [40] to run through the “Resilience” module to reduce general stress complaints □ When GHQ-score ≥4, following actions include: Step 1: employee fills out additional validated questionnaires specifically for depressive- (BSI-DEP [44]) and anxiety (BSI-ANG [44]) symptomsStep 2a: in the case that one or both scores > 0.41:□ Discuss possible causes of complaints □ Consider specialized interventions □ Assess the psychosocial work environment [45] □In the case of first, mild depressive symptoms, consider giving education, psycho-education or an online self-help course “Color your life”, or problem-solving therapy and regular control (national depression guideline [41]) and arrange for follow-up appointment within 6 wk □ Consider a combination of cognitive–behavioral interventions and relaxation in the case of depressive complaints [45] □ Arrange for follow-up appointment within 6 wk	□ Consider after diagnosis, medication and/or treatment or therapy according to national guideline [41] □ When increasing personal abilities by specialized interventions does not result in any effects within 6 wk, with a mild to average depression for a period longer than 3 mo or in the case of severe or recurrent depression: treatment with pharmacotherapy and/or psychotherapy (for criteria choice of treatment consult the national depression guideline: for occupational physician [41])	□ Discuss temporary adjustments in work content □ In the case of impairments in work, advise employee to discuss outcome with manager
		Step 2b: in the case of none of the scores > 0.41:□ Discuss causes of complaints □ Support when necessary in taking recovery steps by simple cognitive–behavioral interventions, e.g. offering a rational perspective, daily structures, positive restructuring [46] □ Enhance problem-solving abilities of the employee, manager and assess the interaction between both [46]
Work-related fatigue	Score VBBA scale “Need for recovery” [30] > 5	□ Discuss influence of fatigue on work–life balance □ Discuss recovery opportunities [29] during the workday □ Advise using the “Burnout” module on www.ephysicianhealth.com [40] to prevent burnout or the “Resilience” module □ In the case of severe complaints, consider using the Maslach Burnout Inventory [47] and arrange for occupational disease notification when: score scale depersonalization ≥ 10 and/or score scale emotional exhaustion ≥ 27 □ When available, use burnout guideline [48] □ Follow up within 6 wk		□ Consider organization interventions proposed by Dunn et al (2007) [49] to improve work–life balance: - when possible, adjust the work to the aim of the hospital physician - Discuss the possibility of flexible working schedule - Discuss possibilities to put more emphasis on the interests of the hospital physician - Temporary reduction of the administrative tasks □ In the case of impairments in work, advise to discuss outcome with manager □ Discuss risk factors of workload (time pressure, deadlines, quantity of work), recovery opportunities, work–rest balance, social relationships.
Work ability
Work ability	When score first item of Work Ability Index [19] ≤ 5	□ Discuss situational causes □ Discuss influence on work functioning and work–life balance □ Investigate causes of reduced individual capacities and start suitable interventions to increase work ability □ Advise employee to have a solution-orientated conversation with their manager □ Arrange for follow-up appointment within 6 wk
Other health aspects in relation to  work	Signaling question “yes”	□ Discuss health complaint and influence on work functioning
Cardiovascular diseases
Calculate score risk profile	Orange	Age < 45 y:
	Male: score risk profile < 30 with risk factor smoking or obesityFemale: score risk profile < 35 with risk factor smoking or obesity	□ When risk factors are present, give targeted lifestyle advices or, when risk factors are absent, give generic lifestyle advice (using www.testuwleefstijl.nl) [50] and/or refer to the “Weight, nutrition and fitness” module on www.ephysicianhealth.com. Employees currently having diabetes or cardiovascular diseases:□ Discuss whether there are impairments in work □ Discuss whether the employee is currently under specialized control Orange:□ Give lifestyle advice targeted at the risk factors present and/or refer to www.ephysicianhealth.com [40] to follow the “Weight, nutrition and fitness” module.
Continuing for heart- and coronary-diseases	Red:	Red:
	Male: score risk profile ≥ 30Female: score risk profile ≥ 35and/oremployee currently having diabetes or cardiovascular diseases	□ Discuss results and give lifestyle advices □ Discuss whether the employee prefers to have an extended profile assessed by the general practitioner or by the occupational physician. In the latter case: □ Perform additional lab research (lipids spectrum and blood glucose level) □ Complete a risk profile using SCORE □ Risk communication □ Give targeted and specific lifestyle advice □ Follow up according to national standard DM2, CVRM, obesity, quit smoking, LTA chronic kidney damage □ When accessible, use NVAB “Healthy nutrition and exercising in the workplace” guideline [51]

AUDIT-C, Alcohol Use Disorders Identification Test-Consumption; COPD, Chronic obstructive pulmonary disease; CVRM, Cardiovascular Risk Management; DM2, Diabetes Mellitus Type 2; EMDR, eye movement desensitization and reprocessing; ENT, ear, nose, throat; GHQ, General Health Questionnaire; LTA, National Transmural Appointment (in Dutch: Landelijke Transmurale Afspraak); NVAB, The Netherlands Society of Occupational Medicine (in Dutch: Nederlandse Vereniging voor Arbeids- en Bedrijfsgeneeskunde); PEP, postexposure prophylaxis; PTSD, post-traumatic stress disorder; VBBA, Vragenlijst Beleving en Beoordeling van de Arbeid (Dutch: The Dutch questionnaire on the experience and assessment of work).

Discussion

In this study, we described the development and content of a job-specific WHS for hospital physicians and medical residents. Information regarding occupational exposures, job demands, work-related health effects, and job requirements was used to follow a step-wise decision process aimed at deciding which job-specific aspects should be included in the WHS. By taking this approach, the ILO guidelines were followed to ensure that the WHS was based on occupational exposures, job demands, and job requirements of the job at hand [12]. Such a job-specific approach of a WHS is widely advocated above a general approach because it enables interventions that best fit the occupation of interest and is, therefore, most likely to increase the effectiveness of the interventions. However, the process of arriving at a job-specific WHS in this way is not widely spread or known and has not been described in international literature. Therefore, the step-wise procedure described in this study sheds an important light on how to decide on the content of a job-specific WHS and might, therefore, serve as a good example for developing a WHS in other (high-demand) jobs.

As a consequence of the lack of clear descriptions of how to arrive at the content of a job-specific WHS, some of the decisions made in the step-wise procedure are expert-based and lack an evidence-based foundation. Our decisions were guided by taking into account the main purposes of the WHS as described in the Dutch guideline [13]: to prevent work-related health complaints and to maintain or improve the health and work ability of hospital physicians. To arrive at these goals, the guideline describes what to consider in each of the different steps in developing a job-specific WHS and, therefore, served as an aid, although it required us to give the exact interpretation of each of these steps for the specific job of hospital physicians. As an example, it guided our decision to include health effects that might be low in prevalence but high in negative effects on health or work ability in order to prevent diminished work-related health and ensure good work functioning and quality of care.

While most of the previously reported intervention strategies among hospital physicians have focused on treatment or counseling of hospital physicians or other healthcare workers when they have been reported sick [53], [52], the job-specific WHS developed in this study can serve as a periodic preventive measure for early detection of work-related health effects. In the present hospital settings, the professionals do not adopt a preventive attitude and show a lack of confidentiality, leading to avoidant help-seeking behavior, self-diagnosis, and self-treatment [55], [54], which means that taking a preventive approach is rather new and might be an effective measure to decrease the number of hospital physicians that continue to work while sick [56].

The quality of work of a hospital physician can be negatively impacted by a reduced health status and can thereby threaten patient safety [10]. For example, the quality of patient interactions is reduced and the risk of making errors is increased when a psychological health complaint is present [58], [59], [57]. Although the main focus of the WHS is usually on the prevention of the negative health effects that can occur due to job demands and occupational exposures of a specific job [12], the negative effects of diminished health on quality of work seem equally important because it might impose risk on others, i.e., patients. Therefore, the job-specific WHS also offers a strategy to maintain or improve quality of care and help secure patient safety.

Although the developed job-specific WHS might contribute to maintaining or improving the health of hospital physicians and subsequently act as an aid in maintaining high quality of care, its efficacy and effectiveness needs to be investigated. However, before doing that, it is recommended to focus on potential program failure first and to investigate whether this job-specific WHS for hospital physicians can actually be implemented in practice [60]. One important aspect of effective implementation is that the target population, i.e., hospital physicians, acknowledges the needs and potential benefits of the program for their own health and work functioning [60], [61]. The job-specific approach in developing this WHS by investigating specific job demands, job requirements, and negative health effects helps address this important aspect. In addition to addressing the needs of the target population, it is important to understand the perspectives of all the different stakeholders involved [62], [60]: the board of the hospital, the physician's board, the medical managers of each medical specialty, the occupational health services, and the occupational physician. This is necessary to arrive at the optimal means of communication and organization that will influence the feasibility and acceptability of the intervention [62].

In conclusion, describing the process of developing a job-specific WHS for hospital physicians, as well as the final content, can serve as an example in taking a more job-specific approach in preventing work-related health and work-functioning problems in other (high-demand) jobs. Due to the job-specific nature, the WHS for hospital physicians can contribute to maintaining good quality of care and securing patient safety by taking care of the care giver.

Conflicts of interest

The authors have no conflicts of interest to declare.