- Email: [email protected]
Assessing men and jobs in industry
182 i n t e r m e d i a t e chronic cases not requiring active treatment or skilled nursing. It is m y opinion that the sanatorium is n o t the place for this type of case which should be accomm o d a t e d in hostels p r o v i d e d by L.A.s u n d e r the p o w e r of Section 28 of the National Health Service Act. F e w such hostels exist at present, and it is to be h o p e d that, w h e n the necessary funds and materials are available, schemes will be developed along these lines. M a n y beds in fever hospitals are no longer required for their original purpose, and there appears to be a tendency to utilise these beds for cases of a non-infectious nature, e.g., chronic sick or medical cases. T o what better use could t h e y be put than t h e admission of the tuberculous ? W h e r e facilities for treatment are not possible, these beds m i g h t be occupied by the chronic bedridden type of case. M a n y M . O . H . s are m e m b e r s of Hospital M a n a g e m e n t C o m m i t t e e s and I w o u l d suggest that they advise strongly against the use of fever hospital beds for other than infectious cases. T h e Minister of Health, in Circular (R.H.B.)64/50, issued in July, 1950, stated that he d e e m e d it necessary to a u g m e n t the insufficient resources of sanatoria and tuberculosis hospitals by the use of a proportion of beds in general hospitals for tuberculous cases, and asked Regional Hospital Boards to apportion for the admission of cases of respiratory tuberculosis as m a n y beds as reasonably possible in suitable general hospitals. It is n o w almost two years since this proposal was m a d e and a n u m b e r of beds has been m a d e available for tuberculous cases in these hospitals. H o w ever, the tuberculous case requires special care and u n d e r standing and these, in the main, are not forthcoming in the general hospitals. A better solution w o u l d appear to be the regrouping of fever hospitals, so that some of these could be m a d e available entirely for the tuberculous. T h e nursing staff could be seconded from a general hospital in the same group. T h e waiting list for cases requiring chest surgery is, in some areas, as long as three years. Could n o t some fever hospitals be converted into chest surgical units of, say, 100 beds ? T h e same circular states that, with the present shortage of beds, the available accomm o d a t i o n m u s t be used as advantageously and economically as possible and goes on to r e c o m m e n d that the use of beds should be limited, so far as practicable, to recoverable cases. As, at present, there is seldom a suitable institution to which the chronic infectious non-recoverable case m a y be sent, in view of this recommendation, m a y there not be a tendency on the part of Chest Physicians to discharge infectious cases to their homes ? H o m e treatment of the tuberculous is placing a greatly increased d e m a n d on the services of the district nurse. M a n y of these patients are receiving lengthy courses of streptomycin, which necessitates f r e q u e n t visits. A large n u m b e r of injections has to be given over a small area of the body, and I think it is i m p o r t a n t that these nurses should receive some instruction regarding the technique of the administration of this drug. I already know of one unfortunate incident w h e n a patient developed a degree of foot drop, the result of a misplaced injection. T h e r e - e m p l o y m e n t of the tuberculous patient calls for the closest possible liaison between chest clinic, L . H . A . , M i n i s t r y of Labour, and industry. Ex-patients fall into two categories: those who can be allowed to return to their f o r m e r e m p l o y m e n t either at once or by gradual stages of rehabilitation and those for w h o m an alternate means of e m p l o y m e n t has to be found. I am especially interested in the courses run by the Ministry of L a b o u r for training in clerical duties because I think that, here, the M . O . H . can play a useful part. Whereas, formerly, a history of tuberculosis would debar a candidate f r o m embarking on a career in local g o v e r n m e n t with the benefit of superannuation, it is most gratifying to find that this is no longer the case. Further, it is the duty of every L.A. to e m p l o y a percentage o f registered disabled persons. W e are all aware of the difficulty of obtaining shorthand typists in our departments, and it would seem that here is a possible source of supply. Persons so employed at local council offices in the h o m e counties would not be subjected to the strain of travel to inner L o n d o n and, in addition to their supervision
PUBLIC HEALTH, August, 1952 at the chest clinics, their conditions of work and progress w o u l d be known to the M . O . H . either directly or t h r o u g h the head of another department. It is disappointing to find that, in the case of Nationalised Industries, n e w candidates giving a history of tuberculosis are debarred f r o m e m p l o y m e n t , this despite the fact that a person previously employed, who has contracted t u b e r culosis and recovered, is permitted to resume his duties. I understand that the Joint Tuberculosis Council is making strong representation on this matter. In July, 1950, the Minister of Health in Circular 64/50 states that certain recommendations had been m a d e to h i m by the J . T . C . regarding the protection of organised groups of children against the risk of infection by adults suffering from tuberculosis. T h e s e recommendations are to the effect that no person with respiratory tuberculosis should be engaged for e m p l o y m e n t which involves close contact with groups of children, unless and until the disease is certified as arrested. A candidate for e m p l o y m e n t should not be engaged until medical examination, including an x-ray of the chest, has been carried out. Also that persons whose e m p l o y m e n t brings t h e m into close contact w i t h groups of children should have an x-ray of the chest annually. T h e s e recommendations are now being i m p l e m e n t e d by L.H.A.s, the use of mass miniature radiography units being m a d e wherever possible. It is disturbing to find that similar recommendations have not been forthcoming from the Ministry of Education. X - r a y examination of all teachers on appointment, and thereafter at annual intervals, would do m u c h to prevent spread of infection to children, and it is to be h o p e d that present difficulties in attaining this objective may soon be overcome. T h e cost of these examinations could be reduced by the installation of static mass miniature radiography units at the larger chest clinics. Finally, B.C.G. vaccination, at present confined to those sections of the population who are especially at risk, and still largely in an experimental stage in this country, appears to hold out a great hope for the future. It m u s t be e m p h a sised that this is a preventative measure and that it is the duty of L.A.s, u n d e r Section 28 of the N . H . A . Act, to formulate schemes. Regarding segregation during the period of immunisation, special hostels should be set aside for these purposes and maintained by health departments of L.A.s. T h e s e hostels could also be used for emergency segregation of children as a temporary measure, e.g., w h e n the m o t h e r has been diagnosed as suffering from p u l m o n a r y tuberculosis and is awaiting admission to sanatorium. Following the admission of the parent to hospital, these children will be removed from the hostel as they will have then become the responsibility of the children's officer.
ASSESSING M E N A N D JOBS IN INDUSTRY* By J. GWYNNE MORGAN, C.B.E., T.D., M.B., D.P.H.,
Chief Medical Officer, tl/Iond Nickel Company, Ltd. M y subject is the practice of medicine within the factory and I will touch for a m o m e n t on the m o r e intimate aspects of industrial medicine. It will be well, therefore, to describe briefly the industry with which I am connected, because the variety of occupations is such that I feel some of t h e m may bear certain relationship to your work. M y company is engaged in the refining and fabrication of non-ferrous metals. W e import a treated ore f r o m Canada which contains a high percentage of nickel, copper, cobalt, together with precious metals such as silver, gold, platinum, iridium, palladium, rhodium, o s m i u m and ruthenium. Our factories are located in the following centres : Clydach, S o u t h W a l e s - - n i c k e l refinery and chemical salts m a n u facture ; the M i d l a n d s - - r o l l i n g mills, casting departments and the building of electric f u r n a c e s ; S c o t l a n d - - t h e * A paper read to the Services Group, Society of M.O.H., London, March 28th, 1952.
183
PUBLIC HEALTH, August, 1952 manufacture of tubes and turbine plates; L o n d o n - - t h e refining of the precious metals. T h e refining of nickel is done b y w h a t is called " T h e Carbonyl Process " a n d this is associated w i t h a considerable toxic hazard. Nickel c a r b o n y l closely resembles p h o s g e n e , which, you will r e m e m b e r , was a gas u s e d in W o r l d W a r I. T h e p r i m a r y consideration in t h e m a n u f a c t u r i n g or refining o f nickel by this process is t h e provision of adequate supplies o f carbon m o n o x i d e . T h e process consists o f r e d u c i n g nickel oxide to nickel b y m e a n s of h y d r o g e n and b y volatilising this r e d u c e d nickel w i t h c a r b o n m o n o x i d e to f o r m a nickel tetra carbonyl ; the reaction is a reversible one and, at a s o m e w h a t h i g h e r t e m p e r a t u r e , the carbonyl splits into carbon m o n o x i d e and nickel, the nickel b e i n g d e p o s i t e d in a very p u r e state. You will therefore realise that o u r greatest hazard is the escape of nickel carbonyl w h i c h is e x t r e m e l y poisonous. O f p r i m a r y i m p o r t a n c e is fitting the m a n in t h e job, b y p u t t i n g square pegs into square holes, t h u s increasing the w o r k e r ' s efficiency and c o n t e n t m e n t . T o accomplish this I have i n t r o d u c e d a categorisation s c h e m e in m y C o m p a n y ' s works w h i c h f o r m s p a r t o f the p r e - e m p l o y m e n t medical examination, a n d I w a n t to i m p r e s s h e r e that it is n o t a m e t h o d for rejecting people. W h e n a m a n has b e e n examined, the m a n a g e m e n t do n o t w a n t to know, for instance, that s u c h a m a n is suffering f r o m aortic regurgitation or mitral stenosis as this w o u l d m e a n n o t h i n g to t h e m ; also, it w o u l d be a b r e a c h of m e d i c a l ethics if such details were made k n o w n to laymen. W h a t c o n c e r n s the m a n a g e m e n t is w h a t work t h e m a n can do a n d w h a t work h e s h o u l d avoid. Both these c o n d i t i o n s are fulfilled by the following scheme w h i c h is a modified P u l h e e m s , as used in the army.
Assessing the Man W h e n a m a n appears for examination, a b r i e f medical history is first t a k e n ; this includes an account of past diseases, and of illnesses and of any w o u n d s sustained d u r i n g military service w h i c h m a y have affected the applicant. I n addition, enquiries are m a d e a b o u t previous occupational history, w h i c h is i m p o r t a n t in that it m a y suggest special examination, as, for example, an x-ray examination in the case of e x - m i n e r s , w h o m a y be suffering f r o m p n e u m o coniosis or silicosis. T h e patient is t h e n e x a m i n e d and the results classified according to a simple code of seven l e t t e r s - - P , F, N, I, R, V, S. T h e letter P indicates physical powers, F shows locomotor efficiency, N conditions of the ear, nose a n d throat, I the intelligence and m e n t a l m a k e - u p , R conditions of t h e respiratory organs, V the visual standards, and S the skin conditions. Each of the above letters has t h r e e or four degrees, as indicated b y the figures 1, 2, 3 or 4. T h e individual letters will n o w be c o n s i d e r e d .
Code Letter P (Physical Capabilities) E x a m i n a t i o n o f the physical qualities gives one of t h e following results : - P I . Age 19 to 45. Normal in all respects. Height/weight ratio, calculated from the Nylic Standard Table of Heights and Weights, normal. P2. Covers ages up to 18 and men over 45 who have no abnormalities, but where, in the first case, full development has not yet been attained and, in the second case, middle-age is causing a tendency towards corpulence. It also includes men of 19 to 45 who are subnormal to a small degree. The height/ weight ratio allows up to 10% disparity from standard. P3. In this group is found the man who has slight organic lesions which are compensatable, bur who is nevertheless not fit for heavy work. If an applicant for work, he should not be employed; if a long-service employee he should be considered for a lighter job. Not more than 25% disparity in height/weight standard. P4. A man placed in this category has disabilities which are beyond repair; he is unfit for employment and, if already an employee, should be considered for a disability pension.
Code Letter F (Feet and Locomotion) H e r e t h e r e are three grades : - FI. No defects of the feet, no varicose veins, no deformities of the joints. F2. Slight defects only, but which limit movement to some small degree and which will have to be watched in case they progress. F3. Deformities of the feet and legs which have a definite effect on function and render the person unfit for any but sedentary work.
Code Letter N (Ear, Nose and Throat) T h i s is a m o s t i m p o r t a n t g r o u p w h e n t h e m a n has to be placed in a j o b in a chemical works, w h e r e the nose has to give first w a r n i n g of escapes of gas or f u m e s . NI. This indicates complete normality of the ear, nose and throat. N2. Indicates slight abnormalities which do not interfere with the sense of smell but may reduce hearing. N3. Loss of sense of smell and other defects of hearing and grossly defective tonsils.
Code Letter I (Intelligence and Education) T h e evaluation o f the intelligence is an aspect of the medical e x a m i n a t i o n w h i c h is not f r e q u e n t l y m e n t i o n e d . It is, however, of f u n d a m e n t a l i m p o r t a n c e in assessing the w o r k e r ' s " j o b fitness," w h i c h is really the psychiatric aspect of the examination. G r e a t care is necessary w h e n intelligence tests are u s e d ; t h e y s h o u l d be u s e d only b y people w h o are trained to evaluate the results and correlate t h e m w i t h those o f the personal interview. W i t h the above facts in m i n d , the g r a d i n g u n d e r this letter is as follows : - Il. This includes men with a high standard of education and intelligence, technical men suitable for highly skilled work. I2. Under this heading are placed those with normal, average intelligence and no apparent history of psychiatric illness. I3. Persons having a low i~atelligence quotient and fit for unskilled labour only. I4. Unstable and not fit for any employment.
Code Letter R (Respiratory System) G r e a t care is n e e d e d in categorising this system, p a r ticularly in the case of t h o s e to be engaged in m i n i n g , w h e r e t h e r e is a risk of silicosis, a n d in chemical industries, w h e r e there is a risk of the lungs being affected b y toxic gases or fumes. RI. This is a chest which is normal in all respects. R2. There is evidence of slight variation from the normal, such as bronchial catarrh or poor expansion. These cases should not be employed where there is dust or gas hazard. R3. Patients in this group are suffering from diseases such as chronic bronchitis or asthma and, if applicants for work where there is a respiratory risk, should be refused. R4. This group comprises patients suffering from definitely incapacitating diseases, such as tuberculosis, and, if employees, should be pensioned off.
Code Letter V (Vision) Vision is sometimes of great i m p o r t a n c e as a factor in placing employees. C e r t a i n j o b s d e m a n d p e r f e c t vision, e.g., precision i n s t r u m e n t work or w h e r e a c o m p l i c a t e d s y s t e m of signals has to be watched. VI. Normal vision. Can read 6/6 with both eyes, also small type at near range. V2. Slightly below standard, hut can be corrected with spectacles. V3. Poor vision in both eyes, or loss of one eye. In the latter case the applicant must not be employed in any work where there is danger of damage to the sound eye.
Code Letter S (Skin) I f the applicant is to be e m p l o y e d in any w o r k involving a risk o f dermatitis, the greatest care s h o u l d be taken in the e x a m i n a t i o n of his skin condition ; such e x a m i n a t i o n s h o u l d include p a t c h tests. S1. No abnormality in the skin, no rashes, no past history of skin diseases or rash. Skin patch tests negative. $2. No history of skin infection, but the skin tests are positive. The applicant muse therefore not be employed where there is a dermatitis hazard.
PUBLIC HEALTH, August, 1952
184
$3. History of past dermatitis, or has rash on skin and reacts to skin tests. T h e appropriate rating for each letter is inserted, during the examination, in the category space of the Medical Categorisation F o r m . I n the case of applicants for e m p l o y m e n t the applicant brings with him from the L a b o u r Officer an " Application for E m p l o y m e n t " card. I n the " Medical Officer's Remarks " section of this card are written any special notes on the categories which the medical officer wishes the labour officer to consider in deciding whether to employ the m a n or not. Assessing
t h e Job
T h e second aspect of the p r o b l e m is the " J o b Assessment " in terms of the categories. T h e prescribed standards are arrived at, in the first instance, by consultations of a small c o m m i t t e e consisting of the medical officer, the departmental chiefs, the safety officer and the labour officer. Each job in the factory is considered in detail, and a standard code for the j o b is drawn up on the basis of the pooled information and opinions. T h i s code is used as a basis for 12 months, during which the medical officer will have had time to categorise sufficient m e n to allow for comparison and reassessment of the job. T h e category values are, in the first instance, arbitrary, being established according to the c o m m i t t e e ' s ideas of the desiderata of each job. T h e s e values vary considerably. I n order to clarify the m e t h o d employed, the job of manual labouring is taken as an example. T h i s being a heavy job, the applicant needs a high standard of physical f i t n e s s ; therefore the physical grade should be P1. Similarly, as he will have m u c h walking and standing to do, his locomotor standard should be F1. T h e next group, the ear, nose and throat system, is not of great significance for labouring and the G r a d e N 2 will suffice. T h e intelligence grade will be I2 or I3. In a chemical works respiratory risks may be great ; the grading needs will d e p e n d on w h e t h e r the man is to do his work inside or outside the plant ; if he is to work inside the plant the grade must be R1 ; if outside then R2 will suffice. Vision need not be perfect, as there is not likely to be any eyestrain ; therefore the G r a d e V2 will be sufficient. T h e skin group requirements, again, depend on the type of material handled ; if such material is capable of giving rise to dermatitis, S 1 m u s t be the grade : otherwise $2 will be high enough. T h e s e results, w h e n recorded, will read : - JoE : LABOURER
Inside chemical plant
P
F
N
I 2
R
V
S
1
1
2
or
1
2
1
2
2
2
3 2 Outside chemical plant 1
1
2
or
3 F o r recording purposes each j o b is given a category n u m b e r , as shown below. I f the categories of the candidate are compared with the j o b assessment categories, it is i m m e d i a t e l y possible to decide w h e t h e r he is suitable for the j o b ; examples of two candidates, one successful and the other unsuccessful, are given below : - JOB : LABOURER IN CHEMICAL PLANT
CATEGORY NO. 22
Names J. Smith ...... T . Jones ......
P
F
1
1
1
1
3
2
Job categories N I R 2
3
1
M e n ' s categories 2 3 1 1
2
2
V
S
2
1
1
1
2
1
O n comparing these two m e n ' s categories with the standard categories for the job, it is obvious that S m i t h is able to fill this job. Jones, on the other hand, fails. D u r i n g the 12 m o n t h s ' trial previously mentioned, examinations are c o n d u c t e d on not only applicants for the different jobs, but m e n w h o are already e m p l o y e d in them. W h e r e individuals have been engaged for some years in the work, and do not c o m e up to required standards, they are left in the job, and those categories in which they are below standard are entered in red ; those in which they are above the requirements are entered in g r e e n ; those in which they are equal to the standard are entered in black. T h e medical officer, w h e n he has examined all the employees in a given job, t h e n enquires f r o m the departmental chief whether all m e n are doing satisfactory work. If they are, then the arbitrary standards first selected are obviously too high and m u s t be lowered, as some of the old employees are certain to be below the required standard in one or more categories. As an example, the job of fitter in the engineering departm e n t is taken and examined. T h e arbitrary standard first selected was as follows : - P F N I R V S 2 1 1 2 1 1 2 Examination of the employees' categories, based on the red, green and black entries m e n t i o n e d above, gave the following percentages : - P F N I R V S Above standard category 60 109 E q u a l to . . . . 20 80 60 -75 80 -Below 20 20 30 100 25 20 -By enquiry and investigation it was discovered that all m e n engaged did their work satisfactorily ; therefore the first arbitrary code was w r o n g and was revised as follows : - P F N I R V S 2 2 2 2 1 2 2 Percentages based on this revised code were : - P F N I R V S Above standard category 80 80 60 80 100 Equal to . . . . 20 20 40 100 75 20 -Below 25 F u t u r e applicants who come up to the revised standard will now be accepted for this job. ,p
System
J,
Approved
T h e above scheme has been in operation for three years u n d e r the aegis of the writer, and has proved acceptable to applicants, employees and management. T h e applicants and employees approve of it because they realise that it is not intended to exclude but to select and place t h e m in the m o s t suitable work. T h e labour officer and departmental managers, whose co-operation is essential, welcome the scheme because it gives t h e m a simple standard by which to j u d g e the medical officer's decisions as they affect their own men. Again, the recorded results of the examinations as a system of categories m a k e valuable statistical data for any enquiry into the medical standards of the working inhabitants of a particular industry and give a cross-section of those standards for the m e n of employable age in the district where the industry is sited. As an example, the reasons for rejection of applicants are given below as percentages : Disabilities in group Physical ...... (P) Locomotion ... (F) Ear, nose and throat (N) Intelligence ... (I) Respiratory system (R) Vision ...... (V) Skin ...... (S)
Percentage 38-8 7-1 5-1 14.3 19.4 5-1 I0-2
Finally, w h e n it is realised by all concerned, by applicants for work, by employees already serving and by the management, which t e r m includes all staff f r o m the works manager (Concluded at loot of next column)
PUBLIC HEALTH, August, 1952 at the chest clinics, their conditions of work and progress w o u l d be known to the M . O . H . either directly or t h r o u g h the head of another department. It is disappointing to find that, in the case of Nationalised Industries, n e w candidates giving a history of tuberculosis are debarred f r o m e m p l o y m e n t , this despite the fact that a person previously employed, who has contracted t u b e r culosis and recovered, is permitted to resume his duties. I understand that the Joint Tuberculosis Council is making strong representation on this matter. In July, 1950, the Minister of Health in Circular 64/50 states that certain recommendations had been m a d e to h i m by the J . T . C . regarding the protection of organised groups of children against the risk of infection by adults suffering from tuberculosis. T h e s e recommendations are to the effect that no person with respiratory tuberculosis should be engaged for e m p l o y m e n t which involves close contact with groups of children, unless and until the disease is certified as arrested. A candidate for e m p l o y m e n t should not be engaged until medical examination, including an x-ray of the chest, has been carried out. Also that persons whose e m p l o y m e n t brings t h e m into close contact w i t h groups of children should have an x-ray of the chest annually. T h e s e recommendations are now being i m p l e m e n t e d by L.H.A.s, the use of mass miniature radiography units being m a d e wherever possible. It is disturbing to find that similar recommendations have not been forthcoming from the Ministry of Education. X - r a y examination of all teachers on appointment, and thereafter at annual intervals, would do m u c h to prevent spread of infection to children, and it is to be h o p e d that present difficulties in attaining this objective may soon be overcome. T h e cost of these examinations could be reduced by the installation of static mass miniature radiography units at the larger chest clinics. Finally, B.C.G. vaccination, at present confined to those sections of the population who are especially at risk, and still largely in an experimental stage in this country, appears to hold out a great hope for the future. It m u s t be e m p h a sised that this is a preventative measure and that it is the duty of L.A.s, u n d e r Section 28 of the N . H . A . Act, to formulate schemes. Regarding segregation during the period of immunisation, special hostels should be set aside for these purposes and maintained by health departments of L.A.s. T h e s e hostels could also be used for emergency segregation of children as a temporary measure, e.g., w h e n the m o t h e r has been diagnosed as suffering from p u l m o n a r y tuberculosis and is awaiting admission to sanatorium. Following the admission of the parent to hospital, these children will be removed from the hostel as they will have then become the responsibility of the children's officer.
ASSESSING M E N A N D JOBS IN INDUSTRY* By J. GWYNNE MORGAN, C.B.E., T.D., M.B., D.P.H.,
Chief Medical Officer, tl/Iond Nickel Company, Ltd. M y subject is the practice of medicine within the factory and I will touch for a m o m e n t on the m o r e intimate aspects of industrial medicine. It will be well, therefore, to describe briefly the industry with which I am connected, because the variety of occupations is such that I feel some of t h e m may bear certain relationship to your work. M y company is engaged in the refining and fabrication of non-ferrous metals. W e import a treated ore f r o m Canada which contains a high percentage of nickel, copper, cobalt, together with precious metals such as silver, gold, platinum, iridium, palladium, rhodium, o s m i u m and ruthenium. Our factories are located in the following centres : Clydach, S o u t h W a l e s - - n i c k e l refinery and chemical salts m a n u facture ; the M i d l a n d s - - r o l l i n g mills, casting departments and the building of electric f u r n a c e s ; S c o t l a n d - - t h e * A paper read to the Services Group, Society of M.O.H., London, March 28th, 1952.
183
PUBLIC HEALTH, August, 1952 manufacture of tubes and turbine plates; L o n d o n - - t h e refining of the precious metals. T h e refining of nickel is done b y w h a t is called " T h e Carbonyl Process " a n d this is associated w i t h a considerable toxic hazard. Nickel c a r b o n y l closely resembles p h o s g e n e , which, you will r e m e m b e r , was a gas u s e d in W o r l d W a r I. T h e p r i m a r y consideration in t h e m a n u f a c t u r i n g or refining o f nickel by this process is t h e provision of adequate supplies o f carbon m o n o x i d e . T h e process consists o f r e d u c i n g nickel oxide to nickel b y m e a n s of h y d r o g e n and b y volatilising this r e d u c e d nickel w i t h c a r b o n m o n o x i d e to f o r m a nickel tetra carbonyl ; the reaction is a reversible one and, at a s o m e w h a t h i g h e r t e m p e r a t u r e , the carbonyl splits into carbon m o n o x i d e and nickel, the nickel b e i n g d e p o s i t e d in a very p u r e state. You will therefore realise that o u r greatest hazard is the escape of nickel carbonyl w h i c h is e x t r e m e l y poisonous. O f p r i m a r y i m p o r t a n c e is fitting the m a n in t h e job, b y p u t t i n g square pegs into square holes, t h u s increasing the w o r k e r ' s efficiency and c o n t e n t m e n t . T o accomplish this I have i n t r o d u c e d a categorisation s c h e m e in m y C o m p a n y ' s works w h i c h f o r m s p a r t o f the p r e - e m p l o y m e n t medical examination, a n d I w a n t to i m p r e s s h e r e that it is n o t a m e t h o d for rejecting people. W h e n a m a n has b e e n examined, the m a n a g e m e n t do n o t w a n t to know, for instance, that s u c h a m a n is suffering f r o m aortic regurgitation or mitral stenosis as this w o u l d m e a n n o t h i n g to t h e m ; also, it w o u l d be a b r e a c h of m e d i c a l ethics if such details were made k n o w n to laymen. W h a t c o n c e r n s the m a n a g e m e n t is w h a t work t h e m a n can do a n d w h a t work h e s h o u l d avoid. Both these c o n d i t i o n s are fulfilled by the following scheme w h i c h is a modified P u l h e e m s , as used in the army.
Assessing the Man W h e n a m a n appears for examination, a b r i e f medical history is first t a k e n ; this includes an account of past diseases, and of illnesses and of any w o u n d s sustained d u r i n g military service w h i c h m a y have affected the applicant. I n addition, enquiries are m a d e a b o u t previous occupational history, w h i c h is i m p o r t a n t in that it m a y suggest special examination, as, for example, an x-ray examination in the case of e x - m i n e r s , w h o m a y be suffering f r o m p n e u m o coniosis or silicosis. T h e patient is t h e n e x a m i n e d and the results classified according to a simple code of seven l e t t e r s - - P , F, N, I, R, V, S. T h e letter P indicates physical powers, F shows locomotor efficiency, N conditions of the ear, nose a n d throat, I the intelligence and m e n t a l m a k e - u p , R conditions of t h e respiratory organs, V the visual standards, and S the skin conditions. Each of the above letters has t h r e e or four degrees, as indicated b y the figures 1, 2, 3 or 4. T h e individual letters will n o w be c o n s i d e r e d .
Code Letter P (Physical Capabilities) E x a m i n a t i o n o f the physical qualities gives one of t h e following results : - P I . Age 19 to 45. Normal in all respects. Height/weight ratio, calculated from the Nylic Standard Table of Heights and Weights, normal. P2. Covers ages up to 18 and men over 45 who have no abnormalities, but where, in the first case, full development has not yet been attained and, in the second case, middle-age is causing a tendency towards corpulence. It also includes men of 19 to 45 who are subnormal to a small degree. The height/ weight ratio allows up to 10% disparity from standard. P3. In this group is found the man who has slight organic lesions which are compensatable, bur who is nevertheless not fit for heavy work. If an applicant for work, he should not be employed; if a long-service employee he should be considered for a lighter job. Not more than 25% disparity in height/weight standard. P4. A man placed in this category has disabilities which are beyond repair; he is unfit for employment and, if already an employee, should be considered for a disability pension.
Code Letter F (Feet and Locomotion) H e r e t h e r e are three grades : - FI. No defects of the feet, no varicose veins, no deformities of the joints. F2. Slight defects only, but which limit movement to some small degree and which will have to be watched in case they progress. F3. Deformities of the feet and legs which have a definite effect on function and render the person unfit for any but sedentary work.
Code Letter N (Ear, Nose and Throat) T h i s is a m o s t i m p o r t a n t g r o u p w h e n t h e m a n has to be placed in a j o b in a chemical works, w h e r e the nose has to give first w a r n i n g of escapes of gas or f u m e s . NI. This indicates complete normality of the ear, nose and throat. N2. Indicates slight abnormalities which do not interfere with the sense of smell but may reduce hearing. N3. Loss of sense of smell and other defects of hearing and grossly defective tonsils.
Code Letter I (Intelligence and Education) T h e evaluation o f the intelligence is an aspect of the medical e x a m i n a t i o n w h i c h is not f r e q u e n t l y m e n t i o n e d . It is, however, of f u n d a m e n t a l i m p o r t a n c e in assessing the w o r k e r ' s " j o b fitness," w h i c h is really the psychiatric aspect of the examination. G r e a t care is necessary w h e n intelligence tests are u s e d ; t h e y s h o u l d be u s e d only b y people w h o are trained to evaluate the results and correlate t h e m w i t h those o f the personal interview. W i t h the above facts in m i n d , the g r a d i n g u n d e r this letter is as follows : - Il. This includes men with a high standard of education and intelligence, technical men suitable for highly skilled work. I2. Under this heading are placed those with normal, average intelligence and no apparent history of psychiatric illness. I3. Persons having a low i~atelligence quotient and fit for unskilled labour only. I4. Unstable and not fit for any employment.
Code Letter R (Respiratory System) G r e a t care is n e e d e d in categorising this system, p a r ticularly in the case of t h o s e to be engaged in m i n i n g , w h e r e t h e r e is a risk of silicosis, a n d in chemical industries, w h e r e there is a risk of the lungs being affected b y toxic gases or fumes. RI. This is a chest which is normal in all respects. R2. There is evidence of slight variation from the normal, such as bronchial catarrh or poor expansion. These cases should not be employed where there is dust or gas hazard. R3. Patients in this group are suffering from diseases such as chronic bronchitis or asthma and, if applicants for work where there is a respiratory risk, should be refused. R4. This group comprises patients suffering from definitely incapacitating diseases, such as tuberculosis, and, if employees, should be pensioned off.
Code Letter V (Vision) Vision is sometimes of great i m p o r t a n c e as a factor in placing employees. C e r t a i n j o b s d e m a n d p e r f e c t vision, e.g., precision i n s t r u m e n t work or w h e r e a c o m p l i c a t e d s y s t e m of signals has to be watched. VI. Normal vision. Can read 6/6 with both eyes, also small type at near range. V2. Slightly below standard, hut can be corrected with spectacles. V3. Poor vision in both eyes, or loss of one eye. In the latter case the applicant must not be employed in any work where there is danger of damage to the sound eye.
Code Letter S (Skin) I f the applicant is to be e m p l o y e d in any w o r k involving a risk o f dermatitis, the greatest care s h o u l d be taken in the e x a m i n a t i o n of his skin condition ; such e x a m i n a t i o n s h o u l d include p a t c h tests. S1. No abnormality in the skin, no rashes, no past history of skin diseases or rash. Skin patch tests negative. $2. No history of skin infection, but the skin tests are positive. The applicant muse therefore not be employed where there is a dermatitis hazard.
PUBLIC HEALTH, August, 1952
184
$3. History of past dermatitis, or has rash on skin and reacts to skin tests. T h e appropriate rating for each letter is inserted, during the examination, in the category space of the Medical Categorisation F o r m . I n the case of applicants for e m p l o y m e n t the applicant brings with him from the L a b o u r Officer an " Application for E m p l o y m e n t " card. I n the " Medical Officer's Remarks " section of this card are written any special notes on the categories which the medical officer wishes the labour officer to consider in deciding whether to employ the m a n or not. Assessing
t h e Job
T h e second aspect of the p r o b l e m is the " J o b Assessment " in terms of the categories. T h e prescribed standards are arrived at, in the first instance, by consultations of a small c o m m i t t e e consisting of the medical officer, the departmental chiefs, the safety officer and the labour officer. Each job in the factory is considered in detail, and a standard code for the j o b is drawn up on the basis of the pooled information and opinions. T h i s code is used as a basis for 12 months, during which the medical officer will have had time to categorise sufficient m e n to allow for comparison and reassessment of the job. T h e category values are, in the first instance, arbitrary, being established according to the c o m m i t t e e ' s ideas of the desiderata of each job. T h e s e values vary considerably. I n order to clarify the m e t h o d employed, the job of manual labouring is taken as an example. T h i s being a heavy job, the applicant needs a high standard of physical f i t n e s s ; therefore the physical grade should be P1. Similarly, as he will have m u c h walking and standing to do, his locomotor standard should be F1. T h e next group, the ear, nose and throat system, is not of great significance for labouring and the G r a d e N 2 will suffice. T h e intelligence grade will be I2 or I3. In a chemical works respiratory risks may be great ; the grading needs will d e p e n d on w h e t h e r the man is to do his work inside or outside the plant ; if he is to work inside the plant the grade must be R1 ; if outside then R2 will suffice. Vision need not be perfect, as there is not likely to be any eyestrain ; therefore the G r a d e V2 will be sufficient. T h e skin group requirements, again, depend on the type of material handled ; if such material is capable of giving rise to dermatitis, S 1 m u s t be the grade : otherwise $2 will be high enough. T h e s e results, w h e n recorded, will read : - JoE : LABOURER
Inside chemical plant
P
F
N
I 2
R
V
S
1
1
2
or
1
2
1
2
2
2
3 2 Outside chemical plant 1
1
2
or
3 F o r recording purposes each j o b is given a category n u m b e r , as shown below. I f the categories of the candidate are compared with the j o b assessment categories, it is i m m e d i a t e l y possible to decide w h e t h e r he is suitable for the j o b ; examples of two candidates, one successful and the other unsuccessful, are given below : - JOB : LABOURER IN CHEMICAL PLANT
CATEGORY NO. 22
Names J. Smith ...... T . Jones ......
P
F
1
1
1
1
3
2
Job categories N I R 2
3
1
M e n ' s categories 2 3 1 1
2
2
V
S
2
1
1
1
2
1
O n comparing these two m e n ' s categories with the standard categories for the job, it is obvious that S m i t h is able to fill this job. Jones, on the other hand, fails. D u r i n g the 12 m o n t h s ' trial previously mentioned, examinations are c o n d u c t e d on not only applicants for the different jobs, but m e n w h o are already e m p l o y e d in them. W h e r e individuals have been engaged for some years in the work, and do not c o m e up to required standards, they are left in the job, and those categories in which they are below standard are entered in red ; those in which they are above the requirements are entered in g r e e n ; those in which they are equal to the standard are entered in black. T h e medical officer, w h e n he has examined all the employees in a given job, t h e n enquires f r o m the departmental chief whether all m e n are doing satisfactory work. If they are, then the arbitrary standards first selected are obviously too high and m u s t be lowered, as some of the old employees are certain to be below the required standard in one or more categories. As an example, the job of fitter in the engineering departm e n t is taken and examined. T h e arbitrary standard first selected was as follows : - P F N I R V S 2 1 1 2 1 1 2 Examination of the employees' categories, based on the red, green and black entries m e n t i o n e d above, gave the following percentages : - P F N I R V S Above standard category 60 109 E q u a l to . . . . 20 80 60 -75 80 -Below 20 20 30 100 25 20 -By enquiry and investigation it was discovered that all m e n engaged did their work satisfactorily ; therefore the first arbitrary code was w r o n g and was revised as follows : - P F N I R V S 2 2 2 2 1 2 2 Percentages based on this revised code were : - P F N I R V S Above standard category 80 80 60 80 100 Equal to . . . . 20 20 40 100 75 20 -Below 25 F u t u r e applicants who come up to the revised standard will now be accepted for this job. ,p
System
J,
Approved
T h e above scheme has been in operation for three years u n d e r the aegis of the writer, and has proved acceptable to applicants, employees and management. T h e applicants and employees approve of it because they realise that it is not intended to exclude but to select and place t h e m in the m o s t suitable work. T h e labour officer and departmental managers, whose co-operation is essential, welcome the scheme because it gives t h e m a simple standard by which to j u d g e the medical officer's decisions as they affect their own men. Again, the recorded results of the examinations as a system of categories m a k e valuable statistical data for any enquiry into the medical standards of the working inhabitants of a particular industry and give a cross-section of those standards for the m e n of employable age in the district where the industry is sited. As an example, the reasons for rejection of applicants are given below as percentages : Disabilities in group Physical ...... (P) Locomotion ... (F) Ear, nose and throat (N) Intelligence ... (I) Respiratory system (R) Vision ...... (V) Skin ...... (S)
Percentage 38-8 7-1 5-1 14.3 19.4 5-1 I0-2
Finally, w h e n it is realised by all concerned, by applicants for work, by employees already serving and by the management, which t e r m includes all staff f r o m the works manager (Concluded at loot of next column)