Education and Research in Occupational Medicine

INTRODUCTION

W1 Figure 01 The uptake selection process.

This is the first version of an educational post-grade Residency program in Occupational Medicine for medical doctors dated Oct 2017 in Panamá with later revisions to be followed in the "View history" in the Wikiversity program. The program formed the basis for the 36 and 18 months education plans and the establishment of a Department of Research and Education in Occupational Medicine in Panamá. The program was developed on request from the Dean of the Faculty of Medicine, Dr. Enrique Mendoza by Dr. Olaf Jensen, since June 2017. With the approval of the Dean the program was based on the formation of the new Department of Research and Education in Occupational Medicine at the University of Panamá. The training program for the 3 Residents started in Nov 2019. The program with active links to the resource pages: Department of Occupational and Environmental Health Sciences, University of Panamá with link to the Spanish version

Planning

Clinical Occupational medicine has been developed to be oriented towards research on the etiologies and the prevention of diseases. The primary objective for occupational medical specialist is to evaluate the patient´s historical and actual workplace hazardous exposures´ and relation this to the patient´s disease history. The specialty thus contains both an individual-oriented clinical component with emphasis on secondary and tertiary prevention and a community-oriented component with emphasis on primary prevention. In either case, the exposure, the etiological assessment and prevention play a central role. An important basis for the preventive activities is found in the epidemiological research that is highly prioritized in the specialty. The occupational medical practice include clinical patient assessment, exposure and etiological assessment, research and development, as well as teaching and other types of dissemination of scientific knowledge. Occupational Medicine as a recognized medical does not exists in Panama and research in occupational medicine is absent. A review of peer reviewed articles in Latin America related to maritime occupational medicine found only a total of 57 peer-reviewed articles. The main part of the articles comes from Brazil and none from Panama. By analyzing all the research documents originating in Panama in the Science Citation Index Expanded a total number of 4880 documents were found. The main research fields are ecology, botany, zoology, evolution and aquatic biology. Public and occupational health represent 2,7 % of them all A study on the Panamanian health research System by Romero et al. characterizes the system as insufficient to accomplish its operative role of generating knowledge for new health interventions and input for innovations . Another study by Romero et al, illustrates an approach to the context of the Panamanian Health Research System, which characterizes the system as insufficient to accomplish its operative role of generating knowledge for new health interventions and input for innovations . These analyses emphasises the need to develop a National Health Research Policy, which should include long-term plans and a strategy to overcome the asymmetries and gaps between the different actors and components of the current system. Another important historical issue is that the Humboltdian model of higher education is not implemented in Panama and neither in most other Latin American countries. The hypothesis of the historical multiple reasons has been explained, corresponding to Romero et al. due to the prevailing political exclusivism for centuries in Latin America In European and North American universities this model has been implemented with the implication that the professors are obligated to teach, to do scientific research and publish international articles. The model for occupational medicine, presented here is more or less copied from the Danish system with the obligations to publish reseaerch work, teach and do clinical work The policy is to strengthen the evidence-based health practice in occupational medicine by interdisciplinary, collaborative research, education and information activities. The proposed policy for occupational medicine in Panama aims to improve job satisfaction, safety, well-being and good health at work, at home and in the retirement.

W15 Figure 1 The Occupational Medical(OM)system

W16 Figure 2 the Occupational Health (OH) system

Definitions

Occupational safety and health (OSH)is a multidisciplinary field concerned with the safety, health, and welfare of people at work. Occupational medicine, is a part of Occupational Health which deals with the maintenance of health in the workplace, including the prevention and treatment of diseases and injuries. It is the branch of clinical medicine most active in the field of occupational health and safety.

Code of Medical Ethics

The international Code of Medical Ethics forms the basic content of the specific demands of ethics in all the medical specialities. The Spanish version is more elaborated than the English Spanish version. The ethics for occupational physicians are normally seen from two main viewpoints: 1) the legal standing and ethics in job execution; 2) ethics in research on occupational medicine. Among lots of guidelines we choose for a start the International Code of Ethics for Occupational Health Professionals from the ICOH code of ethics and the translation into Spanish ICOH Ethics code in Spanish.

Objectives

The objectives of this program are to develop education of the physicians in the OM specialty to work with a scientific evidence-based preventive approach in the clinical, teaching and research activities. Further to include the WHO definitions and guidelines for primary, secondary and tertiary prevention in the daily clinical work. By introducing these methods, the students and the postgraduates will be educated to work scientifically in all clinical and population based working areas. They will be educated on how to start their own research project, ideally for their thesis as a scientific work presented in a scientific article Definitions: The Residency is a stage of graduate medical training. A resident is a physician who practices medicine in a clinic under the supervision of an attending physician. Occupational medicine, is the branch of clinical medicine that is most active in the prevention of occupational health and safety

Main objectives

1. Education programs for Residency- and CSS-physicians update
2. Seminars and lectures for medical students
3. Continuing education
4. Epidemiological research in international collaboration

Specific objectives

1. Plan, announce, implement and supervise the Resident and CSS specialist updating programs
2. Monitor the quality of the training, research and information dissemination
3. Recruit and educate young and promising epidemiological researchers
4. Keep the epidemiological research program on the highest international standard
5. Disseminate new relevant research information to the public and professionals
6. Keep the staff and students´ health, safety, wellbeing and productivity on top
7. Keep digitalised, transparent financial accounts
8. Keep a digitalised register of students, staff, production of articles, diplomas etc.
9. Release Preventive Health Sciencejournal, regularly
10. Join with other university units and medical specialties, Public Health for example

Advertising for choosing the occupational medical specialty

The program will be announced with information on the research, the clinical and theoretical training. The first step is the introductory training "uptake selection process" where the interested candidates can show interests to be admitted in the Residency program. A meeting for the medical students should be established in the last semester of their education with information on the OM medical specialty with good possibilities to combine research, prevention and clinical work. Present the research plan, the possibilities for research and the daily clinical tasks. There are good arguments for choosing occupational medicine as your specialty:

1. Work professionally to improve the working environment
2. Provide prevention at all levels
3. Insight into and influence on social conditions
4. Good patient contact
5. Interdisciplinary cooperation
6. Varied working day
7. Link between clinical everyday and research work
8. Good supervision and strong research traditions international
9. Great influence on the organization of own work
10. Good opportunities for yourself to improve a specialty under development

THE RESIDENCY PROGRAM

W1 Figure 01 The uptake selection process.

Planning

The residency program will be planned in accordance with applicable laws and regulations in la Gaceta Oficial Digital, Gaceta Oficial Digital, lunes 01 de octubre de 2018 page 11-12 open here. The preparatory work will be organized in a working group with members from UP, Caja de Seguro Social, MINSA and other relevant stakeholders. The clinical education residency plan will be elaborated in cooperation with the relevant clinical departments. Training a group of assistants will be established that can guide the residents through the courses and at the same time verify that the trainees complete the planned areas of competence satisfactorily. The supplemental education (specialty courses, research methodology and research project) is the same for the Residency program and the CSS specialists. In order to have dedicated and skilled candidates for the program, allhave to pass an "uptake selection process" The preparatory work will be organized in a working group with members from UP, Caja de Seguro Social, MINSA and other relevant stakeholders. The clinical education residency plan will be elaborated in cooperation with the relevant clinical departments. Training a group of assistants will be established that can guide the residents through the courses and at the same time verify that the trainees complete the planned areas of competence satisfactorily. The supplemental education (specialty courses, research methodology and research project) is the same for the Residency program and the CSS specialists. In order to have dedicated and skilled candidates for the program, allhave to pass an "uptake selection process" The clinical training program, the specialist courses, the research methodology courses and the research project is supposed to be completed for Residency program over 3 years and 1,5 years for the CSS plan. Department of Occupational and Environmental Health Sciences, University of Panama Go to page ] was created to take care of the training, the research and evaluation of the program. The Research Unit could ideally be developed together with the Public Health Insitute and Public Health Residency program.

The 3-year Residency program

Recidency clinical program	1 sem	2. sem	1. sem	2. sem	1. sem	2. sem	Total
Occupational medical clinic, Introduction	6	6					12
Occupational medical clinic main part						6	6
Psychiatry			6				6
Lung-medicine				6			6
Rheumatology					6		6
General practice or Social medicine
Theoretical education and research 2,5 years	x	x	x	x	x
Total months							36

THE 18 MONTH CSS PROGRAM

There are about 90 medical doctors working as specialist in occupational medicine without having completed a residency program, as such a program was never available. The aim is to update their competencies and certificated as OM specialists together with the creation of an OM specialist residency program. Many of them have a completed a master of occupational health degree from the universities. Though the specialists have many years of clinical patient experience, still an evaluation of their level of competency would be helpful to design the most adequate updating program. The residency program will be planned in accordance with applicable laws and regulations in la Gaceta Oficial Digital, Gaceta Oficial Digital, lunes 01 de octubre de 2018 page 11-12 open here. The first step will be to complete a survey about their present work tasks, previous employments in different clinical departments. Further the survey could include their self-assessed competency related to work related exposures, diagnostics of occupational diseases and their needs for updating of their competency (Table 03) Any gaps that might exist between the actual level of competency and the required competency in the new residency program could be described on an aggregate level. By taking experiences, skills and work tasks in consideration, a relevant program for updating of their actual competences could be constructed and implemented. However after many years of practice as occupational medical specialists we anticipate they obtained a high level of competency. And while the diagnostic methods and the type of industrial work-related exposures change over time it would be meaningful to offer an updating program. Besides the 18 months rotation clinical program, the full course program is proposed to be compulsory for the CSS specialists as well. Each cohort in the CSS update program is expected to complete the clinical part, the courses and the research work within 1,5 year with extension up to 2 years.

Planning of the CSS update program

Establish a mail register of the 90 CSS specialists and plan and execute an electronic survey among about their plans, daily workload and wishes. Invite for a meeting to present the results of the survey the actual proposal that has been acknowledged. Make an estimate for planning of how many should be trained. Clinically focused stays can be organized within the fields of dermatology and neurology. In addition, a focused stay at the orthopedic surgeon department may be completed during the update program.

18 months program

CSS specialist program	1 sem	2. sem	3. sem	Total
Other Occupational medical clinic than your own	6			6
Choose: Lung, Rheuma or Psych General Practice or soc med.		6		6
Choose: Lung, Rheuma or Psych General Practice or soc med.			6	6
Clinical and theoretical education and research 810 hours	x	x	x
Total months				18

THEORETICAL COURSES

The theoretical courses are mainly self-instructive and the same for the Residency and the CSS/ specialists programs. The courses and the Research Project will be about 830 study hours work distributed over the 1,5 years of the CSS program and the first 2-3 years of the residency. The Residency program, will be completed over 3 years. Invitation to enroll in the Residency program will be announced every semester. 3-5 participants are expected in each of the cohorts. The diplomas will be signed when the courses are completed by the responsible teachers and clinical supervisors. The obtained number of educational Credits = number of hours used for the education (estimated to be 830) / the number of hours needed for 1 credit. E.g. if the 1 Credit is 25 study hours (European system) then the number of credits for all the courses = 830/25 = 33 Credits

Company and industry knowledge and risk assessment

During the introductory and main education, knowledge of jobs and risk assessment at workplace visits is obtained. Company and industry knowledge must be obtained in collaboration with CSS. An indicative number of company visits is 10 visits

Integrated research training and research methodology (21 days)

The program is semi-distance. After graduation, the specialist should:

1. Have basic knowledge of quantitative (and qualitative) research methods.
2. Have insight into the applicability of research methods to highlight various issues.
3. be able to apply epidemiological terms
4. Be able to extract relevant knowledge from scientific literature that has used recognized research methods
5. be able to apply basic scientific methods in work and environmental medicine research.

Clinical data monitoring

Patient records in clinics are unique resources that can provide knowledge for better patient diagnostics, treatment and prevention of the working conditions. All specialties can participate in collection of data for research. By using the forms the physicians will identify complaints that are work related and the prevention should be done at work. For a start to complete and analyse 50 schemes would be a great contribution to better knowledge and prevention. The schemes are for Occupational Medicine, General Medicine, Psychiatry, Dermatology and Maritime medicine but other specialties like Rheumatology, Cardiology, Respiratory and Neurological clinics can also benefit by using these schemes. The data can be resused for the research project.

1. Medicina Maritima encuesta sobre enfermedades del trabajo
2. Encuesta enfermedades dermatologia del trabajo
3. Medico familiar Encuesta sobre enfermedades del trabajo
4. Encuesta enfermedades psychiatria del trabajo

The resident physician must complete an occupational medical research project. The project can be based on already collected data that is suitable for the testing of certain hypotheses. The physician must independently make simpler analysis of contexts in data that illustrate the hypotheses set out. The project must be reported at a level that corresponds to the requirements of peer-reviewed journals. To be prepared for the research project, the physicians have to go through this or similar training that ends with publicaiton of a peer reviewed articles. The Blue Risk Survey Program include several programs ready for those who want to finalise a small or larger scientific project in an international context. But the basic reasarch skills to be achived as a requisite to do this research. The project can be based on already collected (Clinical data monitoring) that is suitable for the test of certain hypotheses. Under competent supervision the resident should make simpler analysis of contexts in data to test the hypotheses set out. The project must be reported at a level corresponding to the requirements of scientific peer-reviewed journals. This can be done as a group work or as a single work. The completion of the research project can be extended up to 3 years and includes:

1. Drafting the research protocol
2. Data collection
3. Analyses of the data
4. Writing a scientific article and abstract in the IMRAD-structure
5. Only peer-reviewed articles as references
6. Publication in an indexed scientific journal

The introductory training

To be familiar with the introductory training module is a condition to enter the residency program. The training is mainly self-learning done during the first clinical years. After an interview and evaluation the applicants are admitted to enter the occupational medical residents program. Diplomas will be given after self—study and an interview to assure they are familiar with the following issues and training modules:

1. Electronic research tools
2. The Occupational Medicine Wikibook

1. Draft a research protocol with: problems, objectives, methods and expected results in 100-200 words
2. Present the protocol literature search, reference list in Vancouver format by use of Zotero

Research education

1. Epidemiologia User cahe09 code canalview
2. EPI-Investigacion User cahe09 code canalview
3. Research tools step 2

THE RESEARCH PROJECT

A research project should be completed in a quality corresponding to international scientific peer reviewed article, but due to the relatively few hours scheduled for the it doesn´t need to be published international, only in the "School Journal". The research project can be based on already collected data that is suitable for the test of certain hypotheses, with analysis to test the hypotheses set out. A review based on international published articles would also useful. A proposal for a research project with data-collection in the clinics can be used. The task includes drafting a research protocol, data collection, analysis of data and authoring of a small scientific article by the use of the IMRAD structure and with only peer reviewed articles as the references. This can be done as a group work or as a single work. The completion of the research project can be extended up to 2 years. The research training in occupational medicine consists of

• 20 days of research training, which is mandatory for all doctors in main education.
• The occupational research project that applies to doctors in the Residency and CSS doctors.
• The project may be a peer-reviewed journal article based on original data, a peer-reviewed systematic review or a similar level of scientific work reported (including a submission-ready journal article or PhD project description). In the case of several authors, the educator must be the 1st author. Letters to Editor and the like can not be approved.

Supervisor and project plan

A permanent project supervisor should be assigned and a project plan is drawn up in the first meeting in the Occupational Research Department of the Faculty of Health Sciences. There must be agreement on the project plan, and this must be confirmed by the two occupational clinics that form part of the education program.

• Use of time devoted to research training

All doctors in the Residency and the CSS program must complete a research training course and in connection with this, a research project plan. For this, 10 course days and 10 days for the preparation of the plan are earmarked. It is recommended that this set time be used to plan / participate in the work of the occupational research project.

• Time-off for the research project

The occupational clinics are obliged to devote the required time to completion of the project, which is expected to be 2-3 months. In order to ensure the possibility of sufficient immersion and continuity, the time allocated should consist of 1-3 consecutive periods in the occupational medical recruitment.

• Upon completion

The supervisor will send the project to the postgraduate clinical lecturer in the education system's further education region The chairman sends the project to the clinical professors who designate two assessors who are not inhabited. The assessment will be made within 4 weeks from the clinical professors who have received the project.

Reviewers

1. There must be two assessors, of which min. one must be a senior research professor It is a requirement that the other assessor has significant research experience. The assessors can not be supervisors or co-supervisors for the project in question.
2. The supervisor has the overall responsibility that the educator with the selected project, as specified in a project protocol, will be able to deliver a project that meets the requirements.

Approval

1. If the task meets the requirements, the assessors prepare a reasoned approval.
2. If the project can not be approved in the present form, provide a statement of reasons for this project and an audit guidance to obtain approval if possible.
3. The decision is final. This is in line with the compulsory research training, where there is no appeal, but the possibility of extending deadlines.
4. The assessment itself must not be included in the education logbook, but the relevant supervisor must certify in the logbook that the assessor has approved the project

OTHER COMPULSORY COURSES

This supplemental program is compulsory for both the Residency and the CSS occupational medical physicians upgrade program and include the following training modules: During the introductory and main education, knowledge of jobs and risk assessment at workplace visits is obtained. Company and industry knowledge must be obtained in collaboration with CSS. An indicative number of company visits is 10 visits. The special theoretical courses comprise in total 580 course hours and will be able to extend throughout the course of the education. This program is compulsory for both the Residency and the CSS occupational medical doctors upgrade program and include the following training modules:

Contents

1. Methods for company visits and risk assessment
2. Psycho-social risk assessment and prevention
3. Methods for company visits and risk assessment
4. Injury risk assessment and prevention
5. Ergonomic risk assessment and management
6. Clinical occupational medicine - diagnosis, prognosis and prevention
7. Environmental health risk assessment and prevention
8. International Health strategies applied
9. Research project Management
10. Health Promotion at the workplace
11. National Health Economics
12. Toxicology and hygiene risk assessment and prevention

The idea is that the medical doctors in both programs will complete their training by creating and adding new information to the learning texts under development. That means to create new scientific information for each of the modules instead of being presented for some "digested" text to read and learn. The produced materials will be added to the specific chapters of the textbook. Go to the pages

Documentation of completed modules

This part contains the documentation that will be available for the physicians in the introductory position to have this approved so that they can obtain specialist recognition. The documentation consists of:

1. Approval of compulsory clinical competences and courses
2. Certificate of timely completed theoretical courses and the research training module
3. Certificate of timely completed data collection and simple analysis in the clinics
4. Publication of a peer reviewed article

Digital Logbook

W8 Logbook for clinical training

The digital logbook is an electronic management tool for the physicians, the supervisors and teachers in the residency training process. It is a communication tool to give an overview of development and progress throughout the clinical residency and theoretical education process.

Credit transfer from completed Master of Occupational Health

Credits for the theoretical courses cannot be transferred from a completed Masters education. The Masters of Occupational Health are of doubtful scientific value. This is seen by the fact that scientific articles occupational health have never been published. The master´s thesis do not either comply with the scientific international standards. So because of lack of scientific value, the credits from the Master degrees in Panama cannot be transferred to the Residency and the CSS programs. Workplace visits with documented systematic report of risks assessments and proposal for prevention can be credited after evaluation.

Clinical training programs

The clinical training plans and instructions will be available in good time before start. The diploma will be signed after the courses are completed. All involved clinical departments have approved the residency program. All candidates will have a personalized training program with the tjecklist of all the obligatory training and diplomas for each will be signed. The clinical departments in the specialist training must have an educational chief medical officer. This person will plan the detailed learning in the department and take care that all candidates pass through the training. The trainers will go through a one day training program on how to supervise and plan the training. All clinical departments in the specialist training should have an educational chief medical officer. This person will plan the detailed learning in the department and take care that all residents pass through the training, get the Logbook completed and the diploma be signed. The supervisors/trainers will go through a one day training program on how to supervise, plan the training and complete the Logbook and the Diplomas.

OCCUPATIONAL MEDICAL TRAINING FOR STUDENTS

Lectures based on published studies

1. Follow-up from the biannual health examinations for seafarers with pre hypertension etc
2. Effect on fatal accidents from implementing safety measures in fishing a review study
3. International health and safety survey in 11 countries, 6500 participants
4. Incidence rates of injuries in commercial fishing, a questionnaire study
5. Gab of research on health and safety in fishing in Latin America
6. Social security for seafarers international study
7. Chronic Renal Disease, pesticides and food security

Lectures of selected issues in Occupational Medicine

1. The OM patient record
2. The pattern of occupational diseases in Panama
3. The pattern of dermatological occupational diseases
4. The pattern of musculo sceletal occupational diseases
5. Other ...
6. Inspiration and instruction on how to add new information to the Wikibook
7. The Occupational Medicine Wikibook

Research training 1

The introductory training module, self-learning is needed to be member of the Learning Center. The training is mainly self-learning. After an interview and evaluation the applicants are admitted to start with her/his selected research work, that must be within the running research programs. Diplomas will be given after self—study and an interview to assure familiarity with the following issues in

Research training 1:

1. Electronic research tools
2. Occupational Epidemiology
3. Education and Research in Occupational Medicine
4. Preventive Health Science (Journal)

TASK:

1. Draft a research protocol with: problems, objectives, methods and expected results in <200 words
2. Present the protocol literature search, reference list in Vancouver format by use of Zotero

Research methodology

1. Desarrollo de los métodos científicos en las investigaciones de salud – maritima
2. Clincal case studies as subject for a thesis, methodological advice

Research training

1. Epidemiologia User cahe09 code canalview
2. EPI-Investigacion User cahe09 code canalview
3. Research tools step 2

Other study materials for learning

1. Occupational Medicine https://en.wikibooks.org/wiki/User:Saltrabook#
2. Promover el empleo, proteger a las personas: http://ilo.org/global/lang--es/index.htm
3. Enciclopedia de Salud y Seguridad en el Trabajo http://iloencyclopaedia.org/preface-69563

Students thesis

Students from all centers of the Faculty of Health are invited to do their final thesis within one of the active research programs and get supervision. The data are available in the programs. They will be offered special research training and supervision. Requirement is completed self-study of introductory research training

CONTINUING EDUCATION

Like all professionals, the health professionals are "standing on the shoulders of giants" the antique concept equivalent to the modern "Evidence Based Medicine" concept. A daily use of scientific literature is indispensable in all health practices, research and teaching. Formal continuing education for health professionals should be integrated in the daily activities according to the Hippocratic Oaths: “I will recognize the limits of my knowledge and pursue lifelong learning to better care for the sick and to prevent illness". Continuing education can be integrated in all types of clinical and teaching activities.

Reading scientific articles/ "Journal Club"

Clinical research questions come up during patient treatments, clinical conferences and discussions with colleagues. By quick searching in the literature databases, PubMed, Google Scholar and Cochrane with smartphones, tablets and laptops, abstracts and often the full articles are immediately at hand to be read and discussed. Journal Club also called.

Clinical colloquia

The clinical departments can arrange regular group meetings with reading and discussing selected scientific articles of relevance for their specialty. Keeping a fixed time schedule and day of the week, will help to implement a “scientific reading routine” in the department. One person has to be nominated as the permanent chair of the meetings. For inspiration please click to see: 1) Scientific literature search, storage and use 2) Maritime Clinical Colloquial Network - Wikiversity

Learning from scientific conferences

Professional conferences and seminars are valuable in the informal interactions with other attendees to discuss new ideas of research and clinical practice. While the conferences are not always valuable in the sessions themselves, the unique, personal, and insightful conversations with other people can only happen at such events. Storing of the ppts and abstracts gives possibility for those who attended and for those who could not attend to learn new things. In the maritime occupational health, the conference materials are now being collected and stored (click to see an example: ISMH Abstracts and PPTs )

Introductory research module

The introductory training module is a condition to be registered as a researcher in the OM Research Unit. The training is mainly self-learning. After an interview and evaluation the applicants are admitted to start with her/his selected research work, that must be within the running research programs. Diplomas will be given after self—study and an interview to assure they are familiar with the following issues and training modules:

1. Electronic research tools
2. Preventive Health Science
3. Occupational Epidemiology Surveys
4. Education and Research in Occupational Medicine
5. The Occupational Medicine Wikibook
6. Draft a research protocol with: problems, objectives, methods and expected results in 100-200 words
7. Present the protocol literature search, reference list in Vancouver format by use of Zotero

Clinical surveys

Collecting small-scale data in occupational-, general practice, psychiatric- and dermatologic clinics could be highly valuable to describe the impact of working conditions on the patient´s diseases. The main background is the national sub-reporting of occupational diseases. The method is that the patients are asked to answer some few questions on a form in the waiting room. The medical doctor will then evaluate whether the disease is related to the work or not. Analysis of the data can be done as the medical students´ thesis. Please open to see the forms ready for use:

1. Medicina Maritima encuesta sobre enfermedades del trabajo
2. Encuesta enfermedades dermatologia del trabajo
3. Medico familiar Encuesta sobre enfermedades del trabajo
4. Encuesta enfermedades psychiatria del trabajo

Clinical case reports

Case reports comprise a highly valuated tradition within the medical literature. Writing a clinical case-story is often the first step for the medical students and may be the first step towards a life-long scientific carrier. The clinical case-stories represent a growing importance of valuable clinical medical information in our modern information-flowing times. The CARE guidelines provide a framework to support the need for completeness, transparency and data analysis in case reports and data from the point of care: http://www.care-statement.org/

Scientific goals

The aim is to inspire to use and to produce new knowledge of high credibility based on the newest scientific principles for good conduct of studies. The Equator-network gives the recommendations for different types of studies. The goal is to inspire and educate the students to participate in research and publications in their professional carrier. Selected lectures on will be announced in January and September every year for pre- and post grade students.

Preventive Health Science

The objective of the “Scientific School Journal” is to support continuous learning and to give a forum for “starters” of research projects and for their thesis. The general aim is to contribute to create a culture of scientific research, evidence based health practice and critical thinking. As part of the training a scientific school scientific journal has been established and should be further developed by integration in the University of Panama. The development of the sciences is necessary in a modern society. This includes research training in universities, university-based research and the establishment of research centers and scientific journals. It is recommended to all health, clinical and social or labor professionals who read scientific papers as the main part of continuing education (Hippocrates). The "Science School Journal" should help with learning to read articles is the basis of evidence-based practice and learning methods for use in their own research. This "school of science" journal is part of this trilogy in order to develop research in health and develop society. The "Preventive Health Science" journal is an electronic publication. Its main objective is to serve students in scientific health schools. But also to support in the continuous training for the professionals. The use of everyday scientific literature is a key part of this development. That is to contribute to create a culture of risk prevention based on scientific evidence and a critical thinking. The objective is to create awareness about the factors that improve or damage the environment, in order to preserve the quality of life of the inhabitants of the planet and contribute to social welfare. Publication plan: When a new relevant abstract from an international article has been selected and editorial prepared, it is published quickly. The philosophy is that it is convenient to read a single abstract in Spanish in a few minutes

To begin with we are planning and offering courses in theoretical and practical research training and writing academic papers for students and health professionals working in clinics and health administrations. Participants step by step learn to plan and carry out an epidemiological prevalence study based on an applied questionnaire. Tasks and theses made with scientific rules in schools will be published with high priority.Derechos: Los textos están disponible bajo la Licencia Creative Commons. Este significa, que las obras están libres de restricciones conocidas de derechos de los autores. La Etiqueta de Dominio Público permite que la obra sea descubierta fácilmente, y proporciona información valiosa acerca de la obra.

THE RESEARCH DEPARTMENT

Go to the pages: Department of Occupational and Environmental Health Sciences, University of Panamá

W17 Figure 03 Organisation of OM-Unit

W6 Preliminary Budget 2018-2023

W5 Table 05 Steps to establish the OM Unit

The primary objectives for the OM education program are outlined in the introduction. In order to complete these objectives, an academic team and an adequate organization is needed. The team will organize and take care of the implementation of the clinical and the theoretical pre- and postgrade education programs. Each of the education programs will have a main responsible person.

The research programs

The Occupational Epidemiology Survey Program aims to investigate working and living conditions in all forms of occupational activity and to study the health and living conditions of the population. The goal is to produce scientific evidence for the primary, secondary and tertiary health prevention in all health aspects. The research program is related to the international Program. The coordinators will help new members to get started with their research work and store the data in the Risk Program. All members of the Research Unit can get permission to re-use the stored data for further analysis and publications. There are 5 research programs available at the moment:

1.Clinical data monitoring

The routine data from pre-embarkation health examinations are monitored in different countries. The proportions of pre-hypertension, pre-diabetes, and obesity in the seafaring population will be monitored and the seafarers will be offered early diagnostic and prevention. This monitoring and the analysis of the data will help to point out the most important areas for prevention.

2. seafarers´ repatriations

In case of illness, the seafarers are repatriated to heir home country, which is normally very costly. Very little is known how to reduce the number of these repatriations. The research question is to identify clinical indicators with high predictive value for +/- repatriation, including mental health problems. The objectives are to study the etiological, predictive variables that can be used to reduce the number of repatriations.

3. Transport workers Mental Health Program

The transport workers (including seafaring) face more difficult working conditions in their jobs than employees in other jobs. Their mental health is affected by the environment in which they live, often coupled with long working hours that contribute to stress, anxiety, loneliness, depression and suicide. This proposal seeks to improve the transport ' mental health by introducing a comprehensive, evidence-based mental health promotion program that attracts the youngest workers to choose and to stay in the job. Methods: The theories on empowerment, life-long and problem-oriented learning with inclusion of all stakeholders form the theoretical background. A joint action among the unions, the ship owners, the maritime authorities and a network of universities' research centres in suicide prevention, public health and maritime health departments.

4. Dock workers health and safety intervention program

The employers have the full responsibility for health and safety in the ports but the unions also take initiatives for better health and safety together with the university occupational health research departments. The strength is that the workers know the workplace hazards by own experiences better than the owners and the administrators and therefore are the best to propose how to do the prevention.

5. Seafood workers Mental Health Program

Fishing activity and industrial fishing processing are major contributors to the EU economy where it is crucial to have well-functioning workers. Mental problems are wellknown in the community and at all workplaces but there is a gap of knowledge and lack of systematic mental health promotion in the fishing sector and fishing processing industry.

The objectives are to:

• Create, implement and evaluate a research based mental health promotion program, with an acute mental health function, tailored information and training programs
• To use multidisciplinary research methodology including quantitative (epidemiology) and qualitative (interviews and observations) based social sciences
• Search and integrate relevant existing research, experiences and training programs
• Study the mental health risk factors and the relationship between the risk factors and the impact of the mental health wellbeing
• Study the knowledge, skills and needs for training among the youngest workers in order to create relevant training materials and implement effect full training
• Study the scope, the severity and the root causes of mental health problems in the training centres, in the companies´ administrative units and among the workers
• Focus on the students and the youngest workers´ needs for training in order to plan the most relevant training programs being aware on the gender perspectives
• Develop, implement and evaluate the mental health promotion training programs for the vocational school centres, in the company´s administrative units and among all the workers - based on the research
• Produce evaluated training materials and scientific evidence available to be used by the companies, the students and the workers in the fishing sector and other industrial sectors when the project ends.

Registro de enfermedades relacionadas con el trabajo

Los registros de pacientes en clínicas son recursos únicos que pueden proporcionar conocimientos para un mejor diagnóstico, tratamiento y prevención de las condiciones de trabajo. Todos los tipos de clínicas pueden participar en la recopilación de datos para la investigación. Al utilizar los formularios, los médicos identificarán las quejas relacionadas con el trabajo y la prevención debe realizarse en el trabajo. Para empezar, completar y analizar 100 esquemas sería una gran contribución para mejorar el conocimiento y la prevención. Los esquemas se preparan para medicina general, psiquiatría, dermatología y medicina marítima, pero otras especialidades como las clínicas de reumatología, cardiología, respiratorias y neurológicas pueden beneficiarse al usar estos esquemas.

Patient records in clinics are unique resources that can provide knowledge for better patient diagnostics, treatment and prevention of the working conditions. All types of clinics can participate in collection of data for research. By using the forms the physicians will identify complaints that are work related and the prevention should be done at work. For a start to complete and analyse 100 schemes would be a great contribution to better knowledge and prevention. The schemes are prepared for General Medicine, Psychiatry, Dermatology and Maritime medicine but other specialties like Rheumatology, Cardiology, Respiratory- and Neurological clinics can benefit by using these schemes.

• Medicina Maritima encuesta sobre enfermedades del trabajo
• Encuesta enfermedades dermatologia del trabajo
• Medico familiar Encuesta sobre enfermedades del trabajo
• Encuesta enfermedades psychiatria del trabajo

Evaluation and Strategy

Monthly meeetings with evaluation of the plan, as scheduled in the introduction. A new 5 years plan with budget should be ready for application of fundings after 3 years. Most important to keep Monitor, evaluate and disseminate the existing data bases occupational and public health. Establish funding for younger people to be educated with stay in occupational research units in other countries. the USA and Europe. Keep participation in international occupational health network and the multicountry surveillance of occupational health that is ongoing.

Problem-based learning

The problem based learning method was developed for medical education will be used. The method is based on constructivism and the method represents a paradigm shift from traditional learning philosophy, most often lecture based. In the Problem-based learning, the students learn about a subject through reading, lectures and the experience of solving problems mainly by searching and analysing scientific articles. This process allows for students to develop useful skills for their future practice. The aim is to enhance critical appraisal, skills in literature retrieval, evidence based medicine and encourages continuous learning in a team environment. The students are inspired to work in small groups. It is focused on the student's reflection and reasoning to construct their own learning. Each student takes on a role within the group that may be formal or informal and the role often rotates. The role of the tutor is to facilitate learning by supporting, guiding, and monitoring the learning process. This method is considered ideal for the purpose where the aim is not to learn for remembering but to strengthen the evidence based occupational health practice and research.

Throughout the Residency and the CSS Specialist´s update courses, the students will keep their own learning page in Dropbox or Google Drive. There they can read the assignments and submit their solutions. There will be limited space on how much the students have to write, it means about 200-500 words per assignment, always based on peer reviewed literature and organized in the IMRAD scientific structure. Those who have time can produce power points to be presented for the rest of the group with comments from them.

The courses can be attended at distance except for some few classes with obligatory presence in the beginning, the middle and the end of the courses. By this way the teaching is inclusive, allowing students living outside the capital to participate on equal conditions withtyhose in the city. The ideal for all wherever they live is to form study groups of 2-5 that meet regularly, discuss and solve the suggested assignments. In the group work the contribution of each one has to be pointed out in the presentation.

At the start of the courses, all are requested to be present at the introductory day to learn how to use the digitalized system. This is needed so that the assignments can be read on the smartphone and solved on PCs at the library with Wi-Fi access or by own laptops at home This means that everyone has the opportunity to perform the given assignments and to complete the specialty. The examine will be group wise, but also individually and all need to be active in the learning process.

The theoretical learning takes place in as part time of the clinical work. In order to make it possible to follow the teaching and solve the tasks it is necessary that the clinics allow the students to have the necessary time free. For example, a course day which is planned to be consist of 6 hours, the students need to be exempted from the clinical work for that time. It is convenient that the head of the clinic will write down an agreement to allow for best possible learning environment.

In order to produce the best clincal learning environment, workshops in the clinics will be organised on on how to prepare future specialists. This is included in other medical specialties and the same learning methods can be applied for the OM specialty.

able 5: Overview of the basic clinical and course education for CSS specialists and Residence plan

Table 6: Weekly hours scheme for courses, research training and project (441 hours)

Students´ thesis

Students from all Units of the Faculty of Health are invited to do their final thesis within one of the active research programs under supervision and by the use of the available data in the programs. They will be offered special research Education and

Supervision

The academic staff qualifications

The head of the Research Unit must have academic qualifications corresponding to an international university full professor level. One more of the academic staff should have academic qualifications corresponding to an international university PhD post doc level. Both of them should be active member of one or more international research teams and have at least 1 on-going international research project. Students and post-graduate professionals can join the OM-Unit and do research projects after having passed the introductory research methods learning:

1. Electronic research tools
2. Occupational Epidemiology Surveys
3. Education and Research in Occupational Medicine
4. The Occupational Medicine Wikibook
5. Draft a research protocol with: problems, objectives, methods and expected results in 100-200 words
6. Present the protocol literature search, reference list in Vancouver format by use of Zotero

The teachers should have an extensive scientific research background. The specialist education and the research should be strengthened by collaboration with the The Public Health Unit and the OM-Unit. Working together will strengthen the professional groups in each domain.

COMPULSORY CLINICAL COMPETENCES 36 MESES

The list below sets out the competences the occupational medical specialist should possess on completion of education, with the emphasis on the skills and the required compulsory assessment methods. Competences and the related assessment methods are concretized by using competence cards or other specific guidance.

Competencies to be learned during the occupational medical introduction year

1	Diagnostics, etiological assessment and prognosis	Should be able to make:
1	Exposure assessment	At the basic level perform an exposure assessment and risk assessment in the clinical work regarding ergonomic, physical chemical, biological and psychosocial risk factors
		Under supervision carry out and in writing reports of 5-10 workplace visits
2	Basic occupational patient medical assessment	Under supervision do asessment of the most common occupational disorders: Disorders of the neck shoulder Low back disease Shoulder disorders Elbow and wrist disorders Hips and knee disorders Vibration-induced white fingers Hand eczema Asthma / rhinitis COLD (Chronic Obstructive Lung Disease) Indoor climate-related symptoms Asbestos-related disorders Exposure related mental disorders
3	Risk assessment for pregnant women	Under supervision : carry out risk assessment of pregnant women and breastfeeding the working environment and recommend as appropriate preventive measures or absence reports
4	Conclusion and completion of patients	In cases of well-known occupational medical issues independently formulate diagnose, prognosis, etiological assessment and conclusion
5	Relevant communication	Faced with patients and collaborating partners, establish contact and communicate in a form of trust, empathy and situational sensation. Make a clarification and agreement of the patients´ expectations. Clarify the role of the doctor and the occupational medicine clinic and make sure that the patient understands the purpose of the consultation. Ensure that the patient has understood the conclusion and
6	Relevant patient consent	Make agreements with the patient, the members of the interdisciplinary teams and the workplace about the diagnostics and the mapping of exposure conditions. Ensure that there is relevant consent or legal basis for any collection or disclosure of health and exposure information.
7	Report occupational diseases and injuries	Could report occupational diseases and injuries and advise victims in relation to notification to the relevant Authority
8	Basic workretention	Have knowledge of social medicine possibilities and provide suggestions for action on job retention
9	Workplace visits	Under supervision plan and implement 5-10 workplace visits
10	Health promotion	Could advise patients about risk factors and protective factors in work, environment and lifestyle and the interaction between these andindicate options for reducing risks
11	Education	Participate in the department's professional activities eg. by presentation of articles and internal teaching of colleagues.

Lung medicine

1	Diagnostics, treatment and prognosis	Conduct diagnostic investigation with focus on relevant differential diagnoses To prescribe and interpret answers to common paraclinical investigations and make preliminary diagnosis Indicate overall treatment options Specify prognosis with focus on function level for the following states: Pneumonia Asthma Chronic Obstructive Pulmonary Disease (COLD) Restrictive pulmonary diseases, Including silicosis and asbestos Allergic alveolite # Lung cancer and mesothelioma
2	Spirometry	Perform and interpret spirometry incl. test of reversibility
3	Peak-flow monitoring	Make indication and guidance for peak-flow monitoring, as well as read and interpret outcome
4	Bronchial provocation test	Make indication of and interpretation results of unspecific bronchial provocation test
5	Investigation of specific allergies	Make indication for the investigation of specific allergies (including test and specific IgE)
6	Precipitation antibodies	Interpret investigation for precipitation antibodies
7	Pulmonary function study	Give indication for pulmonary function study with diffusion capacity
8	COPD and asthma	Classify COPD and asthma with regard to function difficulties

Rheumatology

1	Diagnostics, treatment and prognosis	Make a diagnostic with focus on the relevant differential diagnoses and ndependently prescribe and interpret answers to common paraclinical studies Make preliminary diagnosis Provide ordered treatment options and help initiate treatment Specify prognosis with focus on function level for the following modes: hip arthrosis knee cartilage palpitations shoulder disorders, including rotator cuff and periartrose neck disorders including osteoarthrosis Elbow and wrist disorders diffuse pain conditions in the musculature inflammatory arthritis Arthritis urica sarcoidosis
2	Musculo-skeletal	Conduct a clinical study for strength, movement, function and tenderness of the neck, Back, upper and lower extremities hip arthrosis knee cartilage palpitations shoulder disorders, including rotator cuff and periartrose neck disorders including osteoarthrosis Elbow and wrist disorders diffuse pain conditions in the musculature inflammatory arthritis Arthritis urica sarcoidosis
3		Investigate for nervous pressure and medulla influence
4		Distinguish between local and systemic, rheumatological disorders

Psychiatry

1	Diagnostics, treatment and prognosis	Have knowledge of diagnostics with focus on relevant differential diagnoses, including independently prescribe and interpret answers to common paraclinical studies. Could carry out a relevant psychiatric interview, adapted patient condition and theyg iven circumstances so that the patient'situation is being illuminated from a biomedical, Psychological and social perspective. Must have knowledge of the most important diagnostic instruments and knowledge of the content of an objective sychiatric examination and on that background Could carry out such an investigation be able to setup and revise diagnostic onsiderations in connection with the below diagnoses indicate parent Treatment options as well as Psychopharmacological and psychotherapeutic Treatment, as well as physical exercise and participation To initiate treatment and specify prognosis with focus on the following states:
2		Depression Anxiety Post-Traumatic Stress Disorder (PTSD) Prolonged load conditions Somatoform modes Personality Disorders
3		Have knowledge about communication principles regarding psychiatry's patient-patient relationship and ability Apply patient interviews
4		Have knowledge of the use of relevant tools and scales for assessment of the severity of the disease, e.g. Hamilton depression score.

Dermatology

1	Diagnostics, treatment and prognosis	Have knowledge of: diagnostic investigation focusing on relevant differential diagnoses common para clinical studies overall treatment of prophylactic measures prognosis with focus on functioning for the following disorders: contact eczema urticaria The skin's benign and malignant tumors atopic skin disorders Other skin disorders that may illuminate Work-related skin disorders: eg. Seborrhoic dermatitis, rosacea, psoriasis, dematomykosis
2		Explain the theoretical background for Mechanisms of the occurrence of contact eczema
3		Know tools to differentiate between professional and non-business-related contact cases
4		Make indication for and interpreting patch samples

Neurology

1	Diagnostics, treatment and prognosis	Have knowledge of diagnostic investigation focusing on relevant differential diagnoses Have knowledge of common paraclinical investigations Have knowledge of the superior treatment Knowledge of prognosis with focus on functioning for the following disorders: dementia headache peripheral neuropathies cerebrovascular diseases
2		Perform clinical neurological examination
3		Make indication for and interpreting neuropsychological examination
4		Make indication for and interpreting neurophysiological examination
5	Patientkommunication	Establish and manage calls in situations which deals with serious illnesses or crisis situations
6		Coordinate and manage a patient meeting

Communication and teaching

Physicians working in the field of occupational and environmental medicine, through the patient-related work, business assignments, literature studies and research, gain significant knowledge about the environment, including the health and safety of the working environment. In order for this knowledge to be used for prevention, the specialist doctor should be able to convey it to colleagues, other professional groups, companies and communities during teaching, meetings and writting. The dissemination must be adapted to the target groups' academic and linguistic requirements.

After completion of specialist medical training, the specialist must be able to:

1	Education	Schedule and complete teaching medical students, doctors in other specialties, and students on occupational health
2	Communication	Write articles and comments to trade magazines, staff magazines, daily press or similar in electronic media Handle inquiries from the press about occupational and environmental medicine issues

Clinical occupational medicine competences – main education

1	Diagnostics, etiological assessment and prognosis	Should be able to make: Diagnostic investigation and differential diagnostics in collaboration with relevant specialties Business history Exposure assessment Etiological of assessment Assessment of work ability and prognosis In the following conditions:
2	Lung Medicine and allergy:	asthma rhinitis / rhinoconjunctivititis allergic alveolite Chronic Obstructive Lung Diseases Restrictive pulmonary disease, including Asbestos and silicosis pleural plaques Instruct and interpret Peak flow monitoring mhp to assess working relationship
3	Neurology:	toxic encephalopathy Carpal tunnel syndrome Morbus Raynaud, Vibration including: Establish indication for and able to interpret The answer to one cold provocation study Establish indication for and able to interpret Neuropsychological examination at Investigation of toxic encephalopathy
4	Rheumatology:	Disorders of the neck shoulder Shoulder disorders elbow and hand disorders hip and knee disorders diffuse pain conditions in musculoskeletal
5	Psychiatry:	mental stress conditions Depression and anxiety post-traumatic stress condition(PTSD) somatizing states
6	Dermatology:	mumps (irritant / allergic) urticaria
7	Other disorders:	indoor climate related symptoms "multiple chemical sensitivity" / odor hypersensitivity cancerous diseases # infectious diseases # hearing damage # following chemical poisoning # For these modes, diagnostic is not performed but only an assessment of exposure and asessment of Work-related causation
8	Work-retaining and social medicine	Provide social medicine guidance for the patient, workplace, job center Give advice in relation to retirement, flexjob etc., cooperate with and refer to relevant public bodies
9	Asessment and advice to pregnant	Make pregnancy risk assessment for maternal injuries in the working environment
10	Health examinations according to regulations	Have knowledge of directives, announcements etc. about night work, work with lead, etc. and handling of health surveys in this context
11	Group Study	Independent planning and implementation of group survey
12	Advice on risk reduction	Advise patients about risk factors and protective factors in work and environment, lifestyle and the interaction between these, and set options to change these
13	Initiate prevention at work	Propose relevant prevention measures for the patient Identified risk factors in working environment. Including suggesting relevant actions and guide the patient by involvement of safety representative, Security leader, security committee / If necessary contact the CSS in agreement with the patient.
14	Dissemination of knowledge	Communicate knowledge to both patients and relatives as well as non-medical professional instances in an easily understandable and useful manner
15	Complete certificates	Complete certificates and declarations to the Social Services, insurance companies
16	Clinical instructions	Eleborate clinical instructions
17	Project management	Have knowledge of project management, lead and organize a group-investigation or other research project
18	Ethics and confidentiality	Apply relevant administrative rules and laws in the healthcare system guidelines for clinical practice, including collection and disclosure of Information, information gathered consent, compliance with confidentiality, handling of conflicts of interest
19	Resource management	Manage your own resources and your own clinical work in relation to dissemination tasks, prevention as well research and development
20	Internationaloccupational medicine	Knowledge of international occupational medicine and developing countries including: Regulation and organization of occupational health and safety conditions under different conditions and the social importance of globalization

Exposure description and assessment

The basis for making reason and risk assessments is a detailed knowledge of exposure in the relevant environment. The exposure description and assessment may include chemical, physical, biological, ergonomic and psychosocial influences. Therefore, very different methods of collection and assessment of exposure information are used. The work history Is the most commonly used method of clinical work medicine to map out the effects of the working environment. The work history describes chronologically the various employment conditions, tasks and related exposures.

1	Diagnostics, etiological assessment and prognosis	Should be able to make:
1	Chemical	Gases and aerosols Dust and fibers Process assessment (chemical conversion)
2	Routes of exposure	Absorption, inhalation, oral intake passage of placenta barrier
3	Physical	The hand / arm vibration whole-body vibration Noise Temperature and draft ionizing radiation # Basic knowledge of ventilation
4	Ergonomic	Repetivity Force Posture Static load
5	Biological	Infectious microorganisms Allergens
6	Psychosocial factors	Working time Working Volume3) Qualitative requirements Influence Support Effort / reward Violence and threats Interpersonal conflicts
7	Combined	Indoor climate
8	apply methods to collect information on Influences in a work environment	Obtain and evaluate workplace instructions and Data sheets, including recipe- Information on chemical products Assess options and restrictions using Questionnaire to exposure description
9	Apply relevant databases	Medline (pubmed), Toxnet, Vibration databases, Reprotox
10	Have knowledge of and understanding of CSS work control system	Workplace Inspection, Jurisdiction and legal basis, Relevant announcements, etc. Organization of workplace inspection Workplace Inspection Practice, Supervision
11	Do company visits under supervision	Through company visits qualify exposure assessment in connection with patient investigation.
12	Local industrial working conditions	Have knowledge of working conditions within those in the current region largest industries.

Etiological- and Risk Assessment competencies

An assessment of the multiple etiologies is defined as an assessment of whether there is a probable correlation between the exposure and the identified disease or symptoms based on exposure and diagnosis. Risk assessment assesses the likelihood that a given exposure may result in a given health injury in the short or long term, or may affect the prognosis

After completion of the specialist medical training, the specialist must be able to

1	Diagnostics, etiological assessment and prognosis	Should be able to make:
1	Know how to use the general principles for etiological risk assessment	Assess risk objectives: Relative risk, Absolute risk, aetiological fraction Explain the fundamental mechanisms of action. Interpret and summarize results of in vitro experiments, animal experiments and human data in relation to the particular one issue Apply different acceptance criteria depending on the context, eg. for the following areas: Chemical influences Physical effects Ergonomic influences Biological influences Psychological Impact
2	Chemical Etiologicals and risk assessments	Explain fundamentally toxicology
3	Physical, risk assessment	From naturally occurring influences, eg. background radiation
4	Ergonomic etiological and risk assessment	Explain the mechanism of action, including importance of work position,speed and power consumption at movements and the significance of inactivity
5	Biological etiologies´ risk assessment	Know mechanism of action incl. Infections, toxic and allergic influence Interpreting controlled biological experiments, eg. climate chamber trials
6	Psychological risk assessment	Explain the importance of known risk factors and interaction with individual resources and coping strategies
7	Cross-etiological risk assessments	Evaluate multiple effects of for example shift work Evaluate multiple influences, eg. In the indoor climate or in pregnant women
8	Individual vulnerability	Explain Individual Vulnerability: Genetics, including atopy, age, social Inequality, inactivity
9	Risk Communication	Make risk communication under different risk perceptions
10	Risk Management	Be able to make a plan for concrete risk management

Communication and teaching competencies

Physicians working in the field of occupational and environmental medicine, through the patient-related work, business assignments, literature studies and research, gain significant knowledge about the environment, including the health and safety of the working environment. In order for this knowledge to be used for prevention, the specialist doctor should be able to convey it to colleagues, other professional groups, companies and communities during teaching, meetings and writting. The dissemination must be adapted to the target groups' academic and linguistic requirements.

After completion of specialist medical training, the specialist must be able to:

1	Diagnostics, etiological assessment and prognosis	Should be able to make:
1	Education	Schedule and complete teaching medical students, doctors in other specialties, and students on occupational health
2	Communication	Write articles and comments to trade magazines, staff magazines, daily press or similar in electronic media Handle inquiries from the press about occupational and environmental medicine issues

THE GRADUATION EXAM

Having completed all requirements and competences sufficiently, the diploma is signed and given to the candidate as evidence of having acquired the right and the necessary skills to act as occupational medical specialist. The needed documentation of the completed education include:

1. Approval of the completion of the compulsory specialist´s courses
2. Certificate of timely completed research training modules
3. Logbook (or competence cards) for completed compulsory clinical competencies
4. The approved research project completed

A graduation exam is held once a year (last week of May) where the candidates can enrol after having completed the compulsory courses, the clinical stays, the clinical competencies have been obtained, completed the research course and completed a research project at the level of an international publication. During the exam, questions will be asked to assess whether the candidate has acquired the compulsory competency. An external censor is involved. During the evaluation, the national grade scale will be applied for each of the 4 competences.

APPENDICES

1. Occupational Epidemiology Surveys
2. Occupational Medicine Wikibook