Denver Health Physician Finds Her Clinical Identity in Occupational Medicine

A doctor who, before medical school, double majored in biology and theatre. How many of those students are there? After one quick conversation with Dr. Alisa Koval, it’s easy to see how those two passions, paths for the left and right brain, fit together.  

For years, Koval was on a search for the right career, a clinical identity that fit her personality, passions, and skills.  

After four years of undergrad at the University of Michigan, she knew she wanted a career in medicine, but was not convinced that that career would be as a doctor. Koval earned her Master’s in health care administration. The role seemed to fit her and her strengths. “It [health care administration] gave me a sort of platform,” she reflects. “I gained some of the same satisfaction that I did in theater, when it came to crafting a message, speaking in front of groups and communicating with populations. It was a nice hybrid.” 

Out of the assumption that she would remain an administrator, Koval wanted to deepen her approach to the job. “I wanted to come at the role from the perspective of a physician,” says Koval. “Health care administrators are responsible for the health of the organization; for myself, I wanted to make decisions and think about health from the perspective of patients as well, because that's why we're all in medicine in the first place.” 

Marrying administration and medicine 

In between earning her graduate degree and starting medical school, Koval deferred for a year to pursue an administrative fellowship at the Children's Hospital Colorado. The process opened her eyes to the day-to-day issues faced by health care organizations, everything from personnel, to research space, to quality, and community outreach. It helped to her to envision what a career as a physician administrator could look like.  

While studying medicine at Georgetown, Koval felt that the curriculum was geared mostly toward internal medicine and surgery. She was looking for a different path, better suited to who she was and that could combine her skills in patient care, and administration. Koval moved to New York City after graduation and joined an internal consulting team at New York Presbyterian Hospital using the Six Sigma methodology. The role was a good marriage of her new clinical skills and administrative background. Again, she got to see what kind of a difference her unique background could make. 

After graduation, Koval worked as a resident in Emergency Medicine at New York Presbyterian Hospital, where she learned important clinical skills that she still uses today, but also witnessed the end results of lack of health care access for certain populations. “I saw people over and over again for the same problems,” says Koval. “It ended up feeling like I was mostly delivering bad primary care. Ultimately, I realized that I wanted to solve these public health problems, I don't want to just be the band-aid that holds them together.” 

Until this point, Koval’s school and work experience had provided her with the skills and competency to be an excellent physician, but she was still lacking a ‘clinical identity.’ While her program provided a strong clinical component with ample public health work, Koval found the clinical rotations wanting. Fortunately, one of her required rotations included one month practicing occupational medicine at Mount Sinai Hospital.  

Getting off the straight and narrow 

“I had stayed on the straight and narrow path with the traditional medical specialties, but I absolutely loved my occupational medicine rotation and I asked if I could extend it from one month to three. It felt like everything I was interested in came together in one place,” says Koval. 

As if she had not already completed enough schooling, Koval completed her residency in general preventive medicine and public health and decided to tack on a fellowship in occupational medicine. She returned to Colorado with her family and for the last five years, she has worked at Denver Health as the director of the Center for Occupational Safety and Health (COSH). This role has allowed Koval to express her full clinical identity, requiring her to use many of her administrative skills. 

COSH treats a patient population composed of healthcare workers from Denver Health as well as workers from the City and County of Denver. Out of these client relationships Koval was responsible for, she found herself gravitating towards public safety workers. About 60-70% of city employee injuries every year happened to public safety workers. “There's great opportunity to not only help these workers make it to retirement by taking care of their injuries, but there's a lot of room for prevention to deal with their underlying health risks,” says Koval. “I am now treating these high-risk populations and trying to mitigate their risk so that when they finally get to retirement, they can enjoy it.” 

In the clinic, Koval blends her patient-centered clinical care with her public health experience. “It’s actually my job to look at the character of the clinic as a whole and identify opportunities to do public health work by dealing with risks that are present in these populations,” she says. “I get to move in and out from working with individuals and zooming back out to the big picture of what is contributing to their issues.” 

Practicing Total Worker Health® 

Before having words to describe it, Koval was treating her patients with a Total Worker Health (TWH) framework. The National Institute for Occupational Safety and Health (NIOSH) defines TWH as “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness-prevention efforts to advance worker well-being. The TWH approach seeks to improve the well-being of the U.S. workforce by protecting their safety and enhancing their health and productivity.” 

This wholistic approach to treating worker health, safety, and well-being as intrinsically connected is unfortunately not standard in occupational medicine. “Physicians approach occupational medicine in different ways,” explains Koval. “Some do primarily clinical work with individual patients, and there are real constraints at play—from employers, insurance entities— that sometimes limit how deep you can dive into a patient's health. I happen to think it's an opportunity to get to know that person as a whole and treat their overall health.” 

The most obvious way Koval practices TWH is by connecting injured workers with primary care physicians (PCPs) during her visits. She says most people would be shocked to know how few of them have PCPs. “All of our data shows that people who get injured on the job are often not in great shape to begin with. They typically have medical problems that are not managed well and they take longer to recover from procedures. Clinic visits are an opportunity to have that conversation with someone about their general health,” says Koval. 

This wholistic, TWH approach was part of what finally gave Koval her clinical identity. Worker health is not just one thing, with a singular focus, and neither is she. “The patient care aspect of occupational medicine really gives me that clinical identity that I needed and wanted to be part of my career,” she says. “My days in the clinic are the ones I look forward to most every week. That clinical practice informs everything else I do.” 

Koval uses a TWH approach not just in her individual treatment of workers in the clinic, but also to engage
employers. She has spent the last year and a half on a grant from the Anschutz Foundation piloting a Department Physician role with the Denver Fire Department. One day a week, Koval is the acting physician for a wellness screening program she helped to build with the department’s physical and mental Wellness Coordinators.

The team screens 12+ DFD members per session, using a bioimpedance scale for body composition analysis; a video-assisted functional movement screening; and exercise testing (treadmill or stationary bike), for which there are several options. After the screening, firefighters have the option of a physician consultation to discuss their data and lifestyle improvement strategies.  At present, their participation rate exceeds 80%. 

The health screenings provide Koval and her team with a comprehensive understanding of an individuals’ physiology, body composition, and overall health. “Compared to individuals in other professions, firefighters are at increased risk for cardiovascular disease, cancer of all types, and mental health conditions, so we're trying to get ahead of those,” says Koval. “Again, we're trying to look at the total health of the person.”  

Additionally, Koval has been given ‘real estate’ on each fire stations' daily tote board. Typically a TV screen, these tote boards provide firefighters with necessary information for their shift that day. Koval updates the boards with vocation-specific and helpful health promotion and disease prevention messages for the firefighters. 

Health screenings for DOTI 

In a partnership between Denver Health and the Denver Department of Transportation and Infrastructure (DOTI), Koval and a handful of other physicians began doing basic information sessions on employee health in 2018. DOTI commercial driver license holders were often struggling with the health metrics required for their certification exams.  

“We got together with the leaders at DOTI (then called Public Works) and explained, ‘Maybe there's some learning to be done here because employees are surprised when they come in to find that their blood pressure is through the roof and we can't certify them,” says Koval. 

They designed an education program where Koval and a combination of occupational medicine residents and nurses from the clinic would educate workers on what they needed to get a smooth certification. The Denver Health team also performed biometric screenings for workers, providing basic health information including health issues (such as hypertensions or diabetes) that employees might be at risk for. DOTI commercial driver certification success increased by 25% after this program. 

“We took a population where we noticed that the overall health was not great which pertained directly to how well they can do their work,” says Koval. “We came alongside the workers to educate them on their general health and hopefully improve their lives outside of work.” 

Koval gets to help other clinicians discover their identity in her role as associate program director of the Occupational Medicine Program from the Center for Health, Work & Environment at the Colorado School of Public Health. Many residents or fellows work with her directly in rotations at the COSH clinic. “Working with the trainees at COSH is not only fun, but serves as a regular reminder of what makes our specialty unique, and why I was drawn to it in the first place. It is extremely gratifying to play a role in training the next generation of OccDocs.” 

The ACGME estimates that up to 15-20% of physicians end up switching specialties at some point in their careers. Koval reflects on what would have helped her realize her clinical path sooner. “I wish someone had told me that there are definitely more options than just internal medicine and surgery,” she says. “We need those people, but there are ways to be a doctor that involve not just individual patient care. You can use this incredibly powerful skill set to look at a whole population, do outreach, provide new education, and improve someone's health from a completely different direction.”

In Koval’s words, speaking to future or current medical residents, if you are a person who enjoys that big picture as much as you enjoy individual interaction, occupational medicine is something to seriously consider. Who knows, you just may find your own clinical identity in it.