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The specialty of occupational medicine is in peril, in large part because of its reliance on financing by industry, which has powerful incentives to limit costs and to favor physicians who are useful to their employers. Occupational physicians generally practice within the framework of the workers' compensation system. Serious flaws in the incentive structure of workers' compensation constrain objectivity in their practice. Under present law they are unavoidably subject to perverse influences from employers and insurance companies. A fundamental reform of workers' compensation law and practice is urgently needed to separate occupational physicians from the control of employers and workers' compensation insurers, whose interests should not be allowed to override the physicians' integrity or to compromise the specialty.

Thirty years ago, occupational medicine was one of the smallest of all the medical specialties, ignored by most physicians and medical schools. Occupational physicians were more likely to have entered the field through career transition than by residency training. In 1970, governmental agencies sought to transform occupational medicine into a major clinical specialty. Influential groups projected a need for large numbers of physicians in the field. Residency training was expanded, as were other teaching programs. However, industry and its workers' compensation insurance partners were not widely included in these plans. For that reason, among others, many physicians entering the field met with disappointment. About half the corporate positions for occupational physicians have disappeared in the last decade. Private practice opportunities turned out to be much more limited than planners had anticipated. Attempts to bring occupational medicine into the curriculum of the medical schools failed. Many of the residency programs that had been created are now closing. The proposal that occupational medicine create a joint specialty with environmental medicine is not widely accepted by the rest of medicine. Because so few physicians obtain board certification, it appears that the specialty of occupational medicine is returning to its former obscurity.