The evaluation of pulmonary fitness and risk.

In summary, medical evaluation for placement decisions must carefully consider the work requirements and the condition of the individual at the present time and in the future. In all situations, the right of the individual to a job must be balanced against the need to protect the potential worker against any adverse effects. Methods of accommodation of the respiratory-impaired worker must also be considered. As discussed elsewhere in this issue (Chapter 4), there are legal requirements for accommodation of the impaired worker. Accommodation may involve worksite modification, change in work schedule, or change in work practices. Specifically, if an individual cannot meet the exertion requirements of the job, it may be possible to modify them. For example, a punch press operator with chronic obstructive lung disease who is unable to carry the raw materials to the press once a day may be able to work if another worker carries the raw materials or if a suitable mechanical assist device is provided. Furthermore, proper workplace controls can decrease exposure levels; if there is no exposure to a toxic substance, then preexisting disease should not influence placement. In one very provocative study, McGrath demonstrated that with stringent environmental controls, persons with occupational asthma to trimellitic anhydride could continue working safely with this substance. Finally, many persons may be able to work on a part-time basis or during certain shifts. Medical evaluation for proper placement is not a single decision to be made on the basis of a one-time evaluation. An iterative approach may be employed, in which the worker's response to a particular placement may be monitored. In this way, individuals who develop adverse effects will be detected. Follow-up contact between the clinician and the worker in borderline situations should be encouraged both to detect any adverse reactions and to facilitate rapport such that the employee will feel comfortable in relating problems to the clinician. Thus, placement decisions must be made carefully with attention to the many factors involved. Ultimately, the physician must use the best available information when serving as an advisor to the potential employer and to the potential employee.