ADF Health April 2005 - Volume 6 Number 1For debateWhat does a commander expect from medical staff?
Command of an operational unit in the Australian Defence Force demands the utmost from the incumbent. My own experience in command of a warship has taught me that it is not just about being the boss. Along with the perceived privileges of command comes the ultimate responsibility and accountability for everything that occurs in your command, including the leadership, welfare and morale of the people under your command. Joseph Conrad’s description of command at sea is, I think, very instructive in explaining the extent of a captain’s authority and obligations. I found the most important duty I had as a commander was looking after my people. The old adage that if you get your people right, the rest will follow is entirely correct. The Navy’s divisional system is the means by which a captain of a ship ensures his or her people are cared for in all respects, so they can contribute to the operational capability that they are being paid to deliver. As an important aspect of the care of people is maintenance of their physical and mental health, the Navy complements the care provided by the divisional system with medical care from professional medical staff. Of necessity, the captain’s duty of care for the ship’s company requires exchange of information with medical staff. This information is often very personal and sensitive. My purpose here is to outline my own experiences regarding this sensitive area, particularly in light of several recent controversial cases in which courts have found that patient–doctor confidences have been breached, and to suggest some guidelines of how much personal medical information a ship’s captain needs to be told. Need to knowMaintaining the welfare and morale of an individual can be complex, and requires a team effort from the commander, divisional officer and medical staff. Good communication between these team members is essential, as the presentation of symptoms for treatment from a medical officer, while usually isolated to a specific incident or condition, might be but a small part of a complicated mixture of work-, home- and health-related issues. In the case of personal information, good communication does not always require disclosure of all information. The familiar security consideration of the “need to know” is usually a good guide. I have found that, in most cases, I did not need to know the specifics of an individual’s medical condition - only how it would affect that person’s workplace performance, as well as a general idea of what the prognosis was for recovery. In some situations, I did need more detail, if the individual’s employment restrict ions had potential to significantly affect the operational capability of the ship or if it would have a detrimental effect on the health and welfare of other members of the ship. I particularly needed additional detail if an individual was to be evacuated to Australia, requiring the ship to alter operations to facilitate the evacuation. There is no definitive guide for how much medical information to pass on to your captain, but I suggest you try to keep it as general as possible, relating specific details only where a clear duty to do so exists. Such situations would include reducing or preventing a serious or imminent threat to life, health, or safety. I strongly recommend avoiding outright refusal to discuss medical issues with the captain - I have never experienced this with any of the medical staff I have worked with. Although most cases will be very clear, some will cross over the boundaries of medical and divisional lines. These are the most difficult to deal with, especially when the patient has expressed a desire to keep his or her condition as confidential as possible. Examples are unexpected pregnancy while at sea, claims of harassment, stress in the workplace, and expressions of self-harm ideation. I have found that just about every patient had no objection to the medical officer discussing their case with me when either I or the medical officer directly asked for permission, but it is important that the captain maintains that confidence and does not discuss the case with anybody who does not have a need to know, including the sailor’s divisional officer or head of department. Legitimate use of personal informationIn all situations, the ADF is bound by Commonwealth legislation. Legislation relevant to this discussion is the Privacy Act 1988. Commanding officer designates in the Navy receive instruction in the relevant sections of that Act and an operational understanding of it before they assume command, and a legal officer is but a telephone call away. Most aspiring captains of ships have completed several postings leading to their selection for command, often including an executive officer position, where they would invariably have been included in many sensitive personnel matters. For my own part, I had also completed a posting in a personnel-related area where the day-to-day management of people with sensitive issues was the norm. So an important lesson for medical staff is that your captain has already been exposed to a wide variety of sensitive personnel matters, is already experienced, and may have dealt with similar cases before. Privacy issues are important, and your commanding officer will be cognizant of the requirement to protect personal information. However, the legislation and other privacy principles were not created to paralyse the legitimate use of personal information, including health information. As a former captain of a warship, and indeed as the current commanding officer of a naval shore establishment, I would be extremely concerned if I had not acted on personal information in ensuring any of my sailors’ well being. As medical officers, you cannot afford not to involve your captain whenever you are in doubt as to the correct course of action, especially when personal issues venture outside medical requirements into the bounds of what should be divisional support. In many cases, medical treatment alone may not be enough, and you will need your captain’s support in approaching career management agencies or other similar support mechanisms. Remember that your commanding officer is entrusted with a duty of care for all the people under his or her command, and will look for your advice and support in discharging this responsibility. The Sixty Minutes testI have found the simple Sixty Minutes test is the best way to determine the appropriate action in a particularly sensitive or difficult case. Ask yourself if your intended action will stand up to scrutiny should you be held to account by a Sixty Minutes reporter. Don’t just concentrate on your own obligations under the Privacy Act or similar guidelines, but think about the wider ethical issues. Do you have the complete story on what the patient has told you? Is there another reason why the patient is suggesting a particular course of action to you? Perhaps your captain or the fleet medical officer has dealt with similar cases in the past. Ultimately, your test must include the question, “Have I thought of every contingency or possible way ahead for this case?” Your captain is well placed to discuss such questions and you do not have to provide complete details of the case, just enough information so he or she can assist you in reaching a considered treatment plan that holistically includes any necessary divisional support that you may not have thought of on your own. ConclusionCare for the ship’s company is a team effort. You should have direct and exclusive access to your captain whenever you need to. Whenever a doctor or medical sailor asked to speak with me, I made time for them immediately (or as soon as practicable if I was involved in a safety critical task). If you do not have that sort of access to your captain, then you need to discuss the matter as a priority. Your captain will not have any hidden agenda or sneaky desire to put the organisation’s needs first. Your captain, like you, will have your patient’s (sailor’s) needs at the forefront. People are the most important contributor to operational capability, and keeping people ready to deliver capability when and where it is needed will always be your captain’s first priority. (Received 4 Jan 2005, accepted 18 Jan 2005) Comment from Wing Commander Margaret Hine, AM, NSCA CO’s responsibilities are the same regardless of service or whether a CO is in a joint role. The prime question is really how much medical information should a CO be given. I think in general what Nisselle (page 9) has outlined applies. However, I think that medical information can be given without divulging diagnosis and patient confidentiality. The problems arise when COs want more than they should have or need, simply for the sake of “prying”.
HMAS Watson, Watson’s Bay, NSW.Ian Middleton, RAN, Commanding Officer, and Training Authority for Maritime Warfare. Correspondence: Captain Ian Middleton, HMAS Watson, Cliff Street, Watson’s Bay, NSW 2030. ian.middleton@defence.gov.au
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Captain Ian Middleton entered the Navy through the Royal Australian Naval College in 1978. In February 2002 he took command of HMAS Warramunga. From September 2003, he represented the Commander Australian Theatre on the staff of the Comander US Central Command as part of Operation Iraqi and Enduring Freedom. He assumed command of HMAS Watson and the position of Training Authority for Maritime Warfare in January 2004. He is married with two children, is an avid squash player, and enjoys skiing and fine wine.