Occupational and environmental exposure

We thank Michael Schweigert for his attention to our article1 and for raising some interesting questions. Our primary intent was to suggest organizing principles to aid the physician in taking a comprehensive environmental history. We also wished to illustrate the weighing of evidence and a precautionary approach to guide decision-making in the many (if not most) real-life clinical situations where incomplete objective evidence is available.2 For this purpose we used a composite case example, closely based on actual cases.

The example illustrates the physician weighing the evidence for and against a symptom–exposure association and possibilities for intervention, and deciding that the combined weight of evidence was sufficient to recommend a trial removal of the photocopier (Table 1).

We appreciate that there are differing views as to what constitutes reasonable accommodation. This is particularly so in some modern workplaces where people are share space and have diminished control over their environment. Employers have faced liability when reasonable accommodation was not made.8 If an employer was reluctant or unable to accommodate the employee's need, or if the employee's symptoms did not improve with the trial intervention, then the cost of further clinical and workplace investigations could be justified. In this example, the employer was immediately accommodating (also reinforcing to his employee that she was valued), and the experiment was successful, with beneficial results for the employee's health and productivity.

Lynn Marshall Environmental Health Clinic Sunnybrook & Women's College Health Sciences Centre Toronto, Ont. Erica Weir Community Medicine Resident Department of Epidemiology and Biostatistics McMaster University Hamilton, Ont. Alan Abelsohn Department of Family and Community Medicine University of Toronto Toronto, Ont. Margaret D. Sanborn Department of Family Medicine McMaster University Hamilton, Ont.