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| Reporting for duty |
24-Jan-2007 |
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From dealing with battle injuries to ethical conflicts over patient confidentiality, a career in the armed forces is full of challenges.
By Heather
Ferguson
.
AFTER a stint in war-torn Afghanistan, Dr Sam Hay says he is well equipped to deal with the stresses of suburban general practice.
The former army major has just started work as a civilian GP in Leichhardt, in Sydney’s inner west, after five years with the Australian Defence Force (ADF).
One of the most challenging experiences of his military career was a 4.5-month posting to a Coalition forces-run hospital in Afghanistan, where, as well as treating routine illnesses, he resuscitated soldiers with gunshot and blast injuries. The battle injuries were particularly distressing.
“When an injured [soldier] comes through the doors, it’s emotional for you but you are also aware of the effect it is going to have on their family, mates and [the] political pressure back at home,” he says.
He coped by debriefing with Canadian, US and UK colleagues.
“We thought about how the day had gone and we took a lot of pride out of the fact we could honestly say we saved lives,” he says.
Dr Hay was one of an increasing number of GPs in the ADF. Medical recruitment has been boosted by the introduction of a new career structure in 2003 that improved remuneration by linking pay to skills and qualifications rather than rank. About 25% of full-time ADF doctors are now qualified GPs, while about one-third of the remainder are GP registrars.
Despite such reforms, the main attraction of military medicine is unlikely to be financial — annual salaries for ADF doctors range from $53,656 to $164,866. While allowances and other benefits have to be added to this, most of the military GPs contacted by Australian Doctor said they would earn more in private general practice.
But what they did value about their military career was its variety. GPs in the ADF can get additional training in occupational health, medical administration, sports medicine and public health, while deployment work can include providing humanitarian aid as well as military medicine.
“[GPs] can work solo or as the leaders of small multidisciplinary teams on ships or in the field, managing everything from routine medical presentations to serious trauma and multiple casualties,” an ADF spokeswoman says. “They also perform casualty retrieval and aeromedical evacuation.”
Dr Hay’s role as senior medical officer with the First Health Support Battalion in Sydney included advising the commanding officer on clinical matters. Before troops were deployed he would provide advice on diseases and conditions prevalent in the area and on the medical teams and supplies to be sent with the deployment.
Clinically, the workload was similar to the usual general practice load, although in a predominantly male population and with more emphasis on musculoskeletal conditions. Mental health also made up a “decent proportion” of the work, from assessing soldiers’ readiness for promotion to helping with stress or interpersonal problems. Dr Hay rarely encountered cases of post-traumatic stress and attributes the low rate to rigorous review of soldiers before, during and after deployment.
He found it was often easier to get access to acute care for soldiers than for patients in private general practice, and was recently angered by calls to ABCradio station Triple J from former soldiers complaining about poor mental health care.
“We have a very robust psychological support system in the defence forces,” he says. “Chaplains, who operate outside [the] chain of command, provide informal support and are often good at managing problems before they become a crisis.”
Like most ADF doctors, Dr Hay joined the army during medical school. He received a wage, education expenses and other support while training in return for a four-year commitment to army service beginning after his second postgraduate year.
After spending a total of one year on deployment — in Bougainville, the Solomon Islands and Sumatra, as well as Afghanistan — Dr Hay is now looking forward to spending more time with his wife, who is expecting the couple’s first child, although he will continue to have a part-time involvement with the ADF.
Given he worked as a full-time army GP for an extra year after his return-of-service obligation, it’s no surprise Dr Hay is positive about his military career.
“Looking after Australian soldiers in another country when they are helping or defending another country is rewarding,” he says. “It sounds corny, but it’s true. It’s also a chance to travel.”
So what’s the downside?
There is an element of danger, of course — GPs undertake the same weapons and military training as other recruits and, while Dr Hay was not under direct fire in Afghanistan, he admits at times he “did not feel as safe” as he would have liked.
But perhaps more disturbing is the occasional story about potential conflicts between a doctor’s medical ethics and their obligations to the ADF.
The world of the defence forces is often impenetrable to the media, but in 2002 the Sydney Morning Herald obtained logbooks relating to the Tampa crisis, when a Norwegian ship carrying hundreds of rescued asylum seekers was refused access to Australian waters.
The military doctor sent to assess the asylum seekers on board the Tampa was under pressure to complete an assessment of 438 people in 43 minutes because Prime Minister Mr John Howard was due to make a statement in Parliament, the newspaper reported. Four of the asylum seekers were found to need IV drips, one of them an eight-month-pregnant woman. Others were found to be drifting in and out of consciousness, with some not responding to outside stimulus. Yet Mr Howard told Parliament that the initial medical investigation found, “Nobody — and I repeat: nobody — has presented as being in need of urgent medical assistance as would require their removal to the Australian mainland or to Christmas Island.”
In another incident, a navy reservist GP became embroiled in one of the bigger scandals to hit the ADF in recent years. Dr Douglas McKenzie was found guilty of improper conduct after he referred Lieutenant Commander Robyn Fahey to a consultant psychiatrist in the absence of symptoms warranting the referral and without the patient’s knowledge. It also emerged Dr McKenzie had discussed sensitive information about Lieutenant Commander Fahey with her commanding officer. As a result of Dr McKenzie’s referral Lieutenant Commander Fahey was told she was being stood down.
Patient confidentiality can be a troublesome issue in the hierarchical world of the military. Writing in ADF Health in 2004, army GP Dr Peter Morton said the boundaries for the traditional doctor-patient relationship and patient advocacy might need to be “redrawn” for GPs contracted to the military.
“Sometimes commanders can intrude unnecessarily upon the privacy of subordinates, but they often need to be consulted, particularly if a patient has work limitations or problems that put others at risk,” he wrote. “For example, in civilian practice if a patient has depression or a substance abuse disorder it is usually a private matter; in the army it may be essential that the soldier be prohibited from handling a weapon.
“Deciding when and how far to breach strict patient confidentiality can be very difficult.”
ON TOUR WITH THE PM
FEW GPs can boast of having travelled in a prime ministerial motorcade, but the Royal Australian Navy’s Lieutenant Commander Nicole Curtis is one of them.
In 2005, she accompanied Prime Minister Mr John Howard on his VIP plane to an Asia-Pacific Economic Co-operation meeting in South Korea, a visit to Pakistan and Afghanistan, and to the Commonwealth Heads of Government Meeting in Malta.
Lieutenant Commander Curtis joined the navy in 1995, during her last year at university, attracted to the sea by friends already in the service. Watching passing ships as she was growing up in Port Lonsdale, in south-east Victoria, also played a role.
“Ho Chi Minh city [in Vietnam] was the first foreign port the navy took me to and it never got any worse,” she says. “[The navy] is an opportunity to see different parts of the world on a very long, free trip.”
About the time Lieutenant Commander Curtis joined up, the media was having a field day with allegations a female navy doctor had been raped. But Lieutenant Commander Curtis says she has not experienced any significant problems with harassment and points out there are more female than male doctors in the navy.
“I come across the occasional dinosaur, but there’s not been anything I have not been able to sort out myself.”
Initially anxious about dealing with emergencies at sea, Lieutenant Commander Curtis has found the most difficult situations are actually routine general practice problems that can’t be managed with the limited medical supplies on board.
“The things that get to me at sea are weird rashes that I have never seen,” she says.
Emergencies at sea have included AF and a suspected subarachnoid haemorrhage. But her most hair-raising moment was a man-overboard incident in terrible weather. The ship was a week from help and, by the time the man was retrieved, his condition was poor.
“The guy did end up being okay,” she says. “But I was worried because his conscious state kept dropping and he was not very warm.”
For the past three years Lieutenant Commander Curtis has worked as a deputy fleet officer at Maritime Headquarters in Sydney training medics and providing advice to medics and doctors at sea. She will spend the next 12 months away from medicine, studying defence strategy and leadership at the Australian Command and StaffCollege in Canberra.
“I like the opportunity to do different things, see different things,” she says. “Probably one day I’ll settle into community general practice, if there is such a thing, but at the moment I am still getting a lot out of defence and enjoying it.”
FEEL THE FORCE
WHILE cashed-up thrill-seekers are willing to pay big bucks for a ride in a fighter jet, Flight Lieutenant Brent Barker has enjoyed one for free.
As a GP registrar in the Royal Australian Air Force, understanding the physiological effects of flight is an integral part of his job. Barker trains pilots in techniques to overcome the effects of high speed and G-forces, such as tensing the large muscles in their legs and buttocks. Managing decompression illness is another key duty.
During his own flight in an FA18 Hornet fighter jet, Flight Lieutenant Barker experienced G-forces of 6.5.
“It felt like my face was 3ft long and my internal organs were being pushed down,” he says. “Suddenly the weight of my arms was six-and-a-half times normal.”
Initially trained as a pharmacist, Flight Lieutenant Barker joined the RAAF Reserve in 1994. After six years in the reserves and 16 years as a pharmacist, he decided to study medicine. He received a scholarship through the RAAF, eventually joining the GP training program in 2005.
Now in his basic term, he is posted to the remote RAAF Tindal base in the NT. Because his air force work is yet to be accredited as part of his GP training, he also does a couple of sessions in a Katherine practice to meet training obligations.
At Tindal, there are three doctors to look after 650 people and it is not uncommon for Flight Lieutenant Barker to work solo. Typical problems include URTIs, sport injuries and aeromedical retrievals. While the patients are generally fit, serious problems such as diabetes and multiple sclerosis have also been picked up.
As a single man, Flight Lieutenant Barker believes life in the ADF would be tough with a family. He is yet to be deployed overseas, but is prepared for a posting to a danger zone such as Iraq.
“We had people working in ICU at Belad in Iraq last year. I’m looking forward to doing my bit.”
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