Proposed AUTHORS' Reply to Dr. Phil Harber The authors thank Dr. Harber for his detailed comments and his support of our thesis that training more Occupational and Environmental Medicine (OEM) physicians will likely have a strongly positive impact on public health outcomes and health care expenditures in California and the nation. We particularly value his insights about possible refinements to our estimates of the costs of training additional OEM residents, and we expect that if our recommendations were to be implemented in California or other jurisdictions, the legislature would probably explore various budget modifications. Regarding his comments about the inclusion of MPH training as part of an OEM residency, the American Board of Preventive Medicine requires the following: "At least 15 total equivalent hours of graduate-level courses are required in the core coursework areas of biostatistics, epidemiology, social and behavioral sciences, health services administration and environmental health sciences. The minimum 15 credit hours of coursework should appropriately reflect the five content areas listed above to ensure applicants are well grounded in foundational public health knowledge and should be graduate level courses. Courses that may include multiple content areas must meet the equivalent academic requirements and content of the traditional individual courses." As such, a traditional MPH may be able to fulfill these requirements. Anecdotally, applicants to OEM programs may have prior MPH degrees and are accepted to OEM residency programs directly into the second year of the program (for only 1 year of training) if they have a prior a residency on a case by case basis based on the ACGME requirement: "To be eligible for appointment at the OEM-2 level, residents must have completed: (1) a residency program that satisfies the requirements in III.A.2.; and (a) This must include at least 10 months of direct patient care in both inpatient and outpatient settings. (2) at least 50 percent of the requirements for a Master of Public Health or another equivalent degree." As such, institutions can fulfill the graduate coursework in a variety of ways. Some of these programs may be online or taken during evening hours, after clinic shifts for example. OEM residency programs may supplement these courses with additional emphasis on environmental medicine and toxicology through didactics. Dr. Harber questions our projected annual cost to train one additional resident. Our estimated cost includes support for additional faculty, staff, and clinical support, and not merely a resident's stipend and benefits. Of course, we recognize that some academic institutions may have other funding sources for faculty and ancillary support. It is important to note that NIOSH funds have not completely supported OEM residency programs, and many programs rely on such supplemental funding. We appreciate Dr. Harber's attention to the overall value of OEM physicians in their multiple societal roles. Because it is difficult to monetize the value of these additional services, we focused on workers' compensation, where considerable cost data is available. Accordingly, the total estimated return-on-investment from training more OEM physicians would likely be even greater than the projected savings in workers' compensation expenditures. Dr. Harber makes the point that academic medical programs beyond the University of California system may also be well-positioned to host OEM residency programs. From a logistical and legislative standpoint, we focused on the University of California because this approach offers a potentially more streamlined mechanism for allocating state funding. That said, we fully support exploring opportunities to extend funding pathways to other medical institutions that demonstrate interest and capacity to support such programs. After we submitted our paper, the Trump administration announced the near-total elimination of NIOSH (National Institute for Occupational Safety and Health) funding, including its extramural support for Education and Research Centers (ERCs), introducing an unprecedented crisis for OEM residency programs. A recent program director survey revealed that only 3 out of 20 accredited OEM residencies could survive without NIOSH and Health Resources and Services Administration funding, underscoring the catastrophic impact of these cuts. The loss of NIOSH support would decimate the already fragile training infrastructure, with up to 80% of programs at risk of closure, drastically reducing the annual output of OEM physicians—currently about 50 graduates nationwide. This cutback will exacerbate the nation's existing shortage of OEM physicians, with only 3265 board-certified OEM physicians serving over 160 million workers, an aging workforce (over 61% aged 60 or older), and a retirement rate outpacing new graduates. Without a robust OEM workforce, employers face increased workers' compensation costs—potentially billions annually—due to higher medical claims and lost productivity. The absence of OEM expertise would also undermine national efforts to rebuild American industry, as worker safety and regulatory compliance are critical to operational resilience. Moreover, the loss of ERCs, which provide vital research and training, would erode the capacity to address emerging occupational hazards, from climate-related risks to new industrial exposures. To avert this crisis, we urgently recommend restoring and stabilizing NIOSH funding including support for ERCs, and urge the establishment of alternative funding streams for OEM training programs, such as Medicare-supported OEM residencies, and creating state-level OEM training funds to sustain and expand residency programs. Akbar Sharip, MD, MPHLoma Linda University School of Medicine, Department of Preventive Medicine, Loma Linda, CAPaul Papanek, MD, MPHCalifornia Division of Occupational Safety and Health, Long Beach, CADepartment of Environmental and Occupational Health, University of California Irvine, Irvine, CACraig Conlon, MD, PhDAlameda County Public Health Department, San Leandro, CAConstantine J. Gean, MD, MSLiberty Mutual, Inc., Anaheim, CAAlya Khan, MD, MPHDepartment of Environmental and Occupational Health, University of California Irvine, Irvine, CARobert Harrison, MD, MPHUniversity of CaliforniaSan FranciscoSan Francisco, CAManijeh Berenji, MD, MPHDepartment of Environmental and Occupational HealthUniversity of CaliforniaIrvine, Irvine, CA
Sharip et al. (Mon,) studied this question.
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