Greece
OCCUPATIONAL MEDICINE IN GREECE (update JULY 2016)
POPULATION
[Definitions: Employed are persons aged 15 years or older, who during the reference period worked, even for just one hour, for pay or profit or they were
working in the family business, or they were not at work but had a job or business from which they were temporarily absent. Unemployed are persons aged 15-74 who
were without work during the reference period (they were not classified as employed), were currently available for work and were either actively seeking work in
the past four weeks or had already found a job to start within the next three months.
Inactive are those persons who are neither classified as employed nor as unemployed. Economically active population (labour force) are persons either
employed or unemployed. Unemployment Rate is the ratio of unemployed divided by total labour force.]
According to the Hellenic Statistical Authority (ELSTAT), the total population of Greece in the latest census of 2011 was 10.816.286 and the projection for 2016 was
11.533.492. In February 2016, the total population aged 15 years and over, was 9,226,300, of whom 3,603,300 was employed and 1,195,100 was
unemployed (i.e. the economically active population [“labour force”] was 4,798,400). The official unemployment rate (as recorded and calculated in accordance with the
above definitions) was circa 24%. The inactive persons aged 15 years and over were 4,424,900.
OCCUPATIONAL PHYSICIANS (OPs) AND COVERAGE OF WORKING POPULATION BY OCCUPATIONAL MEDICINE (OM) SERVICES
The large majority of the working population (estimated to be circa 85%) is employed either in enterprises with less than 50 workers, or are self-employed.
The Greek occupational health and safety law pertaining to occupational health and safety (which, at least on paper, fully conforms with European Union Law) stipulates
that OM services should be provided only to public and private enterprises with fifty or more workers, or workers employed in smaller enterprises who are exposed to
certain noxious substances such as carcinogens and harmful biological agents. This means that only circa 24% of the employed population (i.e. only the 0.8 million
workers employed in such enterprises) must receive occupational medicine services. It is noted that, virtually, no other enterprises (i.e. none of those which are not obliged
to do so by law) receives OM services.
In reality, occupational medicine services are provided to an as yet unknown fraction of the aforementioned 0.8 million workers by 135 specialists in occupational
medicine, 125 of whom are members of the Hellenic Society of Occupational and Environmental Medicine [HSOEM], and by another, estimated 500 - 800 physicians
legally having the job title “occupational physician”, who, however, hold titles in various medical specialties other than occupational medicine. The law does not
stipulate provision of any occupational medicine services to the self employed working population.
It is noted that, according to the latest EUROSTAT statistics, in 2013, in Greece, licensed practicing physicians (holding any medical specialty or no specialty) were
62,000, which entails a ratio of 627 physicians per 100,00 inhabitants, which is by far the highest number of physicians per 100,000 inhabitants among any other country in
the European Union.
NATURE OF OCCUPATIONAL HEALTH SERVICES
Private and public enterprises and organizations receive OM services by OPs as follows:
By employing individual OPs (i.e. including them among their staff), on a whole time basis, as is the case only in very few large-size companies, or
2. by contracting individual self-employed OPs on a part time basis , or
3. by receiving OM services on a part time or on a whole time basis from a private external Health and Safety Protection and Prevention Service
(EXYPP), which provides occupational medicine and safety services to several enterprises.
PROFESSION
1. TRAINING
Specialisation training in OM fully conforms to current existing European Union Legislation. Following six years of training in a medical school and earning a degree
in medicine, one becomes a qualified physician and is automatically licensed to practice. A physician, immediately after his qualification (i.e. as soon as he earns his
university degree in medicine) may start specialisation training in OM, according to Greek law. This is completed after four years in training in total, which includes the
following parts: 28 months training in clinical specialties in training posts approved by the Ministry of Health (in internal medicine, chest medicine [pneumology],
dermatology, ophthalmology, Ear Nose Throat (ENT) medicine, orthopedics and emergency medicine (including traumatology), 12 months of academic training, and 8
months of practical training, of which 6 months in an organized occupational medicine Service in a private or public enterprise or organization (approved for this
training purpose by the Ministry of Health), and two months in the Center for Occupational Hygiene and Safety (K.Y.A.E.) of the Ministry of Labour. Physicians
specializing in OM may attend academic training either in Athens, organised at the National School of Public Health (ESDY), or in Thessaloniki, co-organized jointly by
the Laboratory of Primary Health Care, General Practice and Health Services Research of the Medical School of the (State) Aristotle University of Thessaloniki, the
Laboratory of Hygiene of the Medical School of the (State) Democritus University of Thrace, and the Department of Occupational and Industrial Health of ESDY.
2. DIFFICULTIES AND DEFICIENCIES IN TRAINING
There are no structured and approved (by an appropriate medical authority) specialization training programs for physicians attending the practical part of their
specialization training in an enterprise. The OPs (specialists in occupational medicine) in the enterprises approved for such training by the Ministry of Health, are
not accredited trainers themselves.
The OPs in hospitals provide OM services to hospital staff only. These are individual OPs. There is an Occupational Medicine Service at one State Hospital only. There
are no occupational medicine outpatient clinics or clinical occupational medicine Departments or Services in hospitals, providing services to employees of enterprises
or to the public in general. Consequently, trainees in OM have fewer chances to deal with and learn from many cases of possible or diagnosed occupational diseases,
during their training.
As allowed by law, the physician (“Registrar”) having the task to manage, to do a large part of the teaching and to coordinate the 12 month long academic training at
the National School of Public Health [ESDY] (during the total four year specialization training period) has not been for many years (and still he is not) a specialist in
occupational medicine himself (because no law specifies that he has to be). ESDY is not a University School. It is decentralized part of the Ministry of Health. Its
professors, however, have the standing of University professors. The post of Professor in Occupational Medicine of this School has remained vacant for several
years and remains so almost every time an incumbent retires.
There has never been and there is not even one Department of Occupational Medicine or one post of full Professor in Occupational Medicine in any Medical
School at a University in Greece. There are only two (two year long) part time postgraduate courses in occupational health, which are also attended by physicians:
One (entitled “Program of Postgraduate Studies in Workplace Health”) is organized by the Medical School of the (State) Democritus University of Thrace, in
Alexandroupolis (capital city of the Thrace Region in North East Greece), and the other (entitled “Occupational and Environmental Health”) is organized by the Medical
School and the Department of Political Science and Public Administration of the (State) National and Kapodistrian University of Athens. The Hellenic Institute for
Occupational Health and Safety (“EL.IN.Y.A.E.”) provides short, continuing education courses on occupational health and safety, which are also attended by physicians
holding specialties other than occupational medicine.
Assessment for the acquisition of the title of specialist in occupational medicine is effected by an Examination Committee of the Ministry of Health only by an oral exam
on completion of specialization training. Neither clinical, nor practical, nor written exams are conducted to that end. As allowed by law, some examiners are not
specialists in occupational medicine themselves.
OCCUPATIONAL MEDICINE PRACTICE
1. MAIN DUTIES OF OCCUPATIONAL PHYSICIANS ACCORDING TO GREEK LAW
a. ADVISORY RESPONSIBILITIES OF OCCUPATIONAL PHYSICIANS (OPs)
1. The OPs make suggestions and recommendations and provide advice to the employer, the employees and to their representatives, in writing or verbally, with
respect to measures that must be taken to protect the physical and the mental health of employees.
2. The OPs provide advice on subjects regarding:
A. The planning, programming, modification of the production process, construction and maintenance of work installations and premises, in accordance with rules of
occupational health and safety,
B. The adoption of measures when new materials are introduced and used in the production process, and on procurement of equipment,
C. a. Matters of work physiology and work psychology, ergonomics and occupational health and hygiene, b. the arrangement and shaping of working posts, c. the working
environment, and d. the organization of the production process,
D. The organisation of a service for the provision of first aid at work,
E. The initial placement and change of working post on account of health reasons, temporarily or permanently, as well as the integration and re-integration of handicapped people into the production process, also by making recommendations
for reforming the working posts.
3. The OPs are not allowed to be used for confirming whether an employee is justifiably (or not) off sick.
b. WORKERS HEALTH SURVEILLANCE BY OPs
1. The OPs carry out medical checks of the employees in relation to their working posts, after they are employed or on changing working posts, as well as periodic medical checks according to the judgment of the Work Inspectors of the Ministry of Labor pursuant to requests by the Occupational Health and Safety Committee (a committee the establishment of which in any enterprise is provided for by Law, when workers in a public or private firm wish to
establish it), whenever the above is not stipulated by law. The OPs take care of the execution of medical examinations and of the measurements of hazardous agents of the working environment in conformity with specific laws
and regulations applicable in each case. The OPs assess the medical fitness of workers to work for specific posts, evaluate and register the examination results, issues certificates concerning the above assessments and
communicates them to the employer. The content of these certificates must secure medical confidentiality.
2. The Ops supervise the implementation of measures for the protection of the health of employees and for accident prevention. To this end:
A. They regularly inspect the working posts and report on any omission and negligence, suggest measures to cope with these omissions and supervise their implementation,
B. They explain to workers the necessity for the correct use of personal protective equipment,
C. They investigate the causes of diseases brought about by work, analyse and evaluate the investigation results and propose measures for the prevention of diseases,
D. They supervise the conformity of the employees with the occupational health and safety rules, inform the employees about occupational health hazards and the means used for their protection.
E. They provide emergency medical care in cases of accidents or sudden illness. Carry out vaccination programmes for the employees at the instruction of the responsible Health Directorate of the
Prefecture in which the enterprise is located.
3. The OPs are obliged to keep the medical confidentiality and the commercial confidentiality.
4. The OPs announce the cases of work related diseases suffered by employees to the Work Inspectorate (to the Centres for Prevention of Occupational health and Safety Risks [KE.P.E.K]) of the Ministry of Labour
through the management of the enterprise in which they work,
5. The OPs are ethically independent in relation to the employer and to the employees.
6. If specific enterprises do not have the necessary infrastructure the OPs are obliged to refer employees elsewhere to have certain necessary complementary examinations as appropriately. Thereafter they are informed
about the examination results and evaluate them.
7. The OPs keep a medical file for each employee. The results of any medical, laboratory and para-clinical tests following examination of an employee are also kept in this file, and they are recorded in the employee’s “Occupational
Health Risk Book”. The OPs also keep securely the medical files of employees exposed to certain noxious (hazardous) agents. These employees must have certain medical examinations and tests in relation to their
occupational exposure by law, whilst medical confidentiality must be kept at all times.
8. The OPs examine any employee (working in the same enterprise where the OPs provide occupational medicine services) who seeks the OPs’ advice with respect to his/her occupational health.
9. The employer is obliged to ask either the Safety Officer (see below) or the OPs , or a private external Health and Safety Protection and Prevention Service (EXYPP), which provides occupational medicine and safety services,
and written occupational health risks assessments of all parts of his/her enterprise.
10. The OPs providing occupational medicine services to Local Government (to Local Authorities, i.e. Municipalities, which are the equivalent of Borough Councils in the UK) can, at their discretion, stipulate any kind of appropriate
medical examinations, tests and vaccinations they deem useful, in addition to those provided for by law for workers in certain high risk jobs.
c. COLLABORATION BETWEEN OCCUPATIONAL PHYSICIANS AND SAFETY OFFICERS (“SAFETY TECHNICIANS”)
The OP and the Safety Officer of an enterprise are obliged to collaborate between themselves and also with the Occupational Health and Safety Committee of the enterprise, where such Committee has been established.
2. DIFFICULTIES AND DEFICIENCIES IN OCCUPATIONAL MEDICINE PRACTICE
Not all Occupational Physicians carry out all the tasks mentioned above, which are provided for by law. The extent to which their responsibilities are dispensed varies, depending on the size, prosperity, management and occupational health and safety culture of each enterprise. As primary health care is not properly and fully developed in Greece (e.g. there are not enough Family Doctors – the equivalent of “General Practitioners” in the UK), occupational physicians perform certain primary health care duties, partly substituting for family doctors. Specialists in OM, for the purpose of diagnosing (or excluding) an occupational disease, or for assessing medical fitness to work, may refer a worker for certain laboratoty tests, only for the purpose of initial diagnosis (according to a very recent Ministerial Decree). By contrast, several employers expect the OP to regularly prescribe medicines and make referrals for tests, as if he were the family physician of a worker. Also, not many occupational physicians carry out written assessments of occupational health risks or initial occupational hygiene measurements. OPs do the best they can, within the limitations imposed on them by the lack of preventive culture, the scarcity of appropriate laboratory facilities, the low status of occupational medicine in relation to other medical specialties, and the current economic crisis in Greece.
There is no structured career for occupational physicians. Process protocols for use in occupational health practice by occupational physicians have very recently been introduced, following the work of a Scientific Committee of the Hellenic Society of Occupational and Environmental Health (HSOEH) and are now implemented in a few private and public enterprises and organizations. Extension of their application in enterprises all over Greece proceeds at a slow pace. There are very few nurses
collaborating with occupational physicians in private or public enterprises and organizations. There is no recognized specialty of occupational health nursing. In many enterprises secretarial, logistical and other necessary support to the work of
the OP is inadequate, or appropriate enterprise surgery premises (and also facilities and equipment) may be absent. There are not enough laboratories for measuring or testing agents related to occupational hazards. Among the few major such
laboratories are those of the Center for Occupational Hygiene and Safety (K.Y.A.E.) of the Ministry of Labour and of the Hellenic Institute for Occupational Health and Safety (“EL.IN.Y.A.E.”).
3. ISSUES RELATED TO DIAGNOSING AND REPORTING OCCUPATIONAL DISEASES
No cases of diagnosed occupational diseases have been reported to date by employers (who should report them, according to law) to the Regional Centres for the Prevention of Occupational health and Safety Risks (“KE.P.E.K.”) of the Ministry of
Labour (which should record them, according to law) since 2009. The employer, according to law, is responsible for reporting such cases, following diagnosis by occupational physicians. More often than not, appropriate past or current
measurements and testing of noxious occupational agents are not available to enterprise OPs, to enable them to diagnose, beyond any reasonable doubt, whether a disease is occupational or not. No sufficient occupational history of patients is
taken or recorded in clinical departments in hospitals. Collaboration between occupational physicians and physicians holding other specialties treating sick workers is scarce.
Another contributory factor for non-diagnosis is probably that many Greek occupational physicians might not have dealt with enough cases of occupational diseases during their specialization training. Furthermore, definite diagnosis of
occupational diseases is pursued by workers only when they wish to claim disability pension. If they do so, a Committee of the Centre for Certifying Disability (KE.P.A.) of the National Insurance Administration (I.KA.) examines the worker who claims it and may disagree with the diagnosis and prognosis of the enterprise OP. As regards workers compensation for occupational injury, the law of tort exists in Greece. Thus, in some circumstances employer and employee might agree on non- reporting a case of an occupational disease. This may happen when the employer benefits the worker (in certain instances, possibly also at the workers’ suggestion) by permanently and unnecessarily assigning unduly lighter or restricted duties to him after he recovers and returns to work (following absence owing to a diagnosed occupational disease). At the same time, the employer does not appear to admit to negligence, i.e. he does not risk to be shown to have been negligent in his duty to provide a healthy and safe working environment, because he avoids having the case taken by the worker to court. This may, however, delay remedial, preventive measures which ought to be taken by the employer to make work healthier. In
Greece, there is not a separate, specific public “Insurance Fund against Occupational Health Risk”, (into which each employer would pay in premiums, the magnitude of which would depend on his firm’s occupational health and safety risk record) which would cover health care and disability pension of workers afflicted by an occupational disease or work accident, as appropriately.
DEFICIENCIES IN LEGISLATION AND ITS ENFORCEMENT
In Greece, the term “Occupational Physician” (OP) is used to signify a specialist in occupational medicine. However, it is used also as a job title for physicians who are not necessarily specialists in occupational medicine; i.e. they may be specialists in
other medical specialties providing certain OM services as best as they can. This anomaly allowed by law has been rectified for the most part by law amendment, following action taken also by the Hellenic Society of Occupational and
Environmental Health ( HSOEH), but it is still partly accepted and allowed by law (even though, by and large, priority must be given by law to specialists in OM when an employer is seeking an OP):
A. for physicians who had been providing OM services as enterprise physicians in various firms without holding the specialty title of OMF for over seven years up until 2009,
B. for physicians who are recruited for the first time after a job in a private or public enterprise was advertised but for which no specialist in OM applied. and
C. in cases where an EXYPP an “external” (i.e. not in-house) private occupational health and safety company, after unsuccessfully advertising to employ a specialist in OM to work for itself, cosigns a contract with a private
or a public enterprise for providing OM services and then assigns this task of providing OM services to a physician who is employed by the EXYPP, but holds a specialty other than OM.
There is no legal obligation for private companies to advertise a post for an occupational physician.
The responsibilities of occupational physicians working in enterprises (either in the public or in the private sector of the economy) are provided for by law. However it may be further specified in their contracts of work, which may vary between
enterprises. Some of these contracts, in certain private or public enterprises and organizations, may not be adequate or even appropriate for a physician, insofar as they may not promote the provision of high quality OM services. A case in point are
posts for OPs offered to the applicant who claims or accepts the lowest remuneration.
Furthermore, none of the Health Work Inspectors of the Ministry of Labour is a specialist in OM (as there is no relevant legal provision for it). These Inspectors are either physicians holding specialties other than OM, or are other health professionals, e.g. chemists. They merely attend a six months long course in occupational health and safety, before they start exercising their duties. Consequently, a paradox occurs: Whenever an enterprise OP makes a written recommendation recorded in the official register “Book of Written Recommendations by the OP” (held, according to law, in every enterprise ) and the employer decides not to conform with it, the Health Work Inspector of the Ministry of Labour must arbitrate, even though he is much less of an expert than the specialist in OM, who has made the recommendation to the employer.
COMMUNICATION ISSUES
Communicating the value of OEM, to employers, educators, workers, and physicians is inadequate. There have been hardly any Congresses on OM in Greece, and very few papers reporting on studies on OM subjects are published in medical journals or presented at Medical Congresses (as compared with the number of papers on subjects of other specialties). On a positive note, the Hellenic Society of Occupational and Environmental Medicine publishes a peer reviewed scientific
journal of occupational medicine. The [bi-partite – established by the Employers and the Employees Associations] Hellenic Institute for Occupational Health and Safety (“EL.IN.Y.A.E.”) publishes a professional journal addressed to employers, managers employees, and all occupational health and safety professionals, including occupational physicians.
There is inadequate collaboration between the Ministries of 1.Health, 2. Labour, and 3. Education, on occupational medicine and occupational health matters. There is virtually no education on issues of occupational workplace hazards and protection against them in primary and in general secondary education. The economic advantages and value of OM cannot be appreciated sufficiently by many employers during the economic crisis currently plaguing Greece. Generally, public opinion does not recognize that OM is a high priority, or that OPs have the same standing as physicians holding other clinical medical specialties. It is noted that OM was recognized and established as a medical specialty in Greece, in 1987.
HOT TOPICS REGARDING OM
The main issues are:
1. Communicating the value of OEM,
2. Improving related legislation and its enforcement,
3. Improving training in OM, and
4. Improving OM practice
5. Improving the diagnosing and reporting cases of occupational diseases.
Tackling these issues is a challenge, whilst unemployment rate is at 24% and Greece has many infrastructural, manpower (e.g. currently, shortage of staff teaching OM) and economic difficulties to overcome.
Dr Theodore Bazas, MD, PhD, FFOM(RCP, London), MSc(London), DIH(Engl)
Specialist in Occupational Medicine (JCHMT, UK),
Current Member (and former Vice-President) of the Hellenic Society of Occupational and Environmental Health, Delegate to the UEMS Section on Occupational Medicine nominated by the Panhellenic Medical Association
Athens, Greece, 22 July 2016