In this symposium we move away from papers dealing with the laboratory, field inquiry and research, into fields which include such concepts as equity, social values, interpretation of laws and statutes, the nature of medical evidence, and similar slippery and treacherous ground. We have heard from speakers from the United States, Britain and Germany so far, and before continuing to hear from Dr. Gaensler and Mr. Richman, I believe it might be helpful to review, very briefly, the subdivisions of topics with which this symposium is concerned, together with some comments on each. My perspective is necessarily limited, but so is everyone else’s— with the possible exception of the Dutch, since I’m told that in Holland no one ever has to make a decision as to whether lung disease is, or is not, related to occupation.
There are three aspects of the measurement of the impairment of function: methodology; objective versus “subjective” tests; and interpretation (pattern of derangement). The fact that choice of methodology is important is self-evident; there is little unanimity on the questions of the importance of exercise testing, for example. As you have heard, the exercise testing procedure in Germany is exhaustive, and clearly in that country a serious attempt is made to define whether any functional impairment has been caused by any occupational exposure, more or less regardless of whether any disability exists, and regardless of characteristic radiologic change. The importance of using test methods which are independent of the patient’s effort is generally recognized, and a recent note in the Lancet of a compensation case in which the FEV had proved unreliable clearly illustrated this point. I have also seen several patients in whom the final decision was more influenced by effort- independent tests than by the FEV.
In particular, mechanics studies and studies of gas exchange and of intrapulmonary gas distribution have proved important in defining the extent of abnormality. The third of the points above poses very real problems and these will be addressed later in the symposium held by My Canadian Pharmacy Inc’s employees and other medical facilities.
The second principal question is the relationship of impairment to occupational or environmental exposures: nature of pathology; relative role of different factors (cigarettes, gases, dust, radiation); and nonspecific pulmonary syndromes.
We very often do not have evidence of the nature of the pathology so this is not available to us. The relative role of different factors in etiology was discussed by a number of speakers yesterday in relation to decisions in men who have worked with asbestos, and I need not expand on the problems that arise in that connection. It must be clear to all of us, however, that very different decisions are probably now being made in different jurisdictions in respect to many of these cases. The problem of nonspecific pulmonary syndromes, particularly chronic bronchitis and emphysema, is recognized by all of us to be an important one and there are considerable differences in relation to this question, not only between different countries but, at least in Canada, between different provinces of the same country.
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