Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: The command asks you in a routine situation to act in a capacity that your professional body would not recognise you as having the correct qualifications or training to perform. What should you do?

List the Issues that arise from the scenario

• Potential harm to patients as well as the safety of the medical staff.

Identify Critical Information required and Assumptions to be made

• Ethics of clinical practice beyond specific competencies.

• What is the specific role/task that is required to be undertaken?

• Could this be assigned to someone with better competence to fill the role?

• Is it possible to receive additional training/experience before taking on the role?

• Does the employer/chain of command accept liability for any adverse outcome arising from your lack of specific qualifications for this role?

Step 2 – ANALYSE

Patient: Patients place their trust in healthcare providers to ensure that they have the proper qualifications, training, and competence to deliver safe and effective care. When a healthcare professional is asked to perform tasks outside their recognised scope of practice, it can affect that trust and compromise the quality of care.

Patients have the right to be fully informed about who is providing their care and whether those involved are properly qualified. If you are asked to perform a task beyond your qualifications and you believe it could impact patient safety, it is essential to address this concern with the patient. By doing so, you uphold the principles of autonomy - ensuring the patient can make informed decisions about their care - and non-maleficence - prioritising the patient's safety and well-being.

Clinical: ‘In armed conflict or other emergencies, healthcare personnel are required to render immediate attention and requisite care to the best of their ability.’ - WMA, ‘Ethical principles of health care in times of armed conflict and other emergencies’. At: https://www.wma.net/policies-post/ethical-principles-of-health-care-in-times-of-armed-conflict-and-other-emergencies/

A healthcare professional performing tasks outside their scope of competence could lead to doubts about the quality of care and increase the potential for errors, harm, or adverse outcomes.

Acting beyond your qualifications can result in clinical errors, patient harm, and ethical dilemmas, making it critical to adhere to your defined scope of practice and seek the appropriate help when needed. - UK General Medical Council. ‘Good Medical Practice. Domain 1. Knowledge, Skills and Performance. Apply knowledge and experience to practice.’ At: https://www.gmc-uk.org/professional-standards/the-professional-standards/good-medical-practice/domain-1-knowledge--skills-and-development

Legal: Your professional body defines your scope of practice, which outlines the tasks and responsibilities you are legally authorised to perform based on your qualifications, training, and experience. Performing actions outside this scope may result in claims of professional negligence, where the patient could argue that the care provided was substandard or inappropriate. Similarly, malpractice could be a significant legal concern.

Medical professionals are expected to uphold ethical standards and act with integrity, ensuring they are accountable for their decisions and actions. - ICRC. ‘Protecting healthcare: Guidance for the armed forces’ 2021. At: https://healthcareindanger.org/wp-content/uploads/2021/03/4504_002-ebook.pdf

Societal/Military: There may be a military necessity if there are staff shortages or everyone in the medical unit has the same level of expertise. Not acting may result in more harm to the patient than acting outside your level of training which wouldn’t conform to a societal duty of using and adapting your medical knowledge to provide patient care.

A medical professional without the correct qualifications may provide care that would otherwise not be accessible for the patient if they were, for example, in a desolated military environment where transport to an appropriate facility with more experienced medical personnel isn’t possible. - ICRC. ‘Protecting Healthcare: Guidance For The Armed Forces’. 2021. At: https://healthcareindanger.org/wp-content/uploads/2021/03/4504_002-ebook.pdf

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

It is not possible to be a specialist in every domain of military medical practice. Indeed there may be limits to the total number of personnel who can be deployed and this might result in an extension of practice for team members compared to normal civilian practice in health facilities in the parent country. Examples could include treating newborns or very young children without being a paediatrician; performing an emergency Caesarean without having done it before, or a secondary care physician being asked to act as a GP for a period of planned leave. - This covers similar issues to 6 Clubs.

While the urgency of military operations may sometimes push personnel into roles beyond their training, there are critical ethical, legal, and practical concerns associated with such practices.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Medical personnel are expected to provide healthcare to their patients to the best of their ability, which also places obligations on their employing organisation to provide training and experience for their role.- Woolley T, Round JA, Ingram M. Global lessons: developing military trauma care and lessons for civilian practice. Br J Anaesth. 2017 Dec 1;119(suppl_1):i135-i142. doi: 10.1093/bja/aex382. PMID: 29161399. At: https://pubmed.ncbi.nlm.nih.gov/29161399/

Dana A, Mohammadimehr M. ‘A study on capabilities required in military medicine to develop modular training courses: a qualitative study.’ J Adv Med Educ Prof. 2017 Jul;5(3):134–147. At: https://pmc.ncbi.nlm.nih.gov/articles/PMC5522905/

Most national professional bodies will have statements regarding the duty to practice within the limits of personal competence (knowledge, training, experience). - UK General Medical Council. ‘Good Medical Practice. Domain 1 Knowledge, Skills and Performance. Apply knowledge and experience to practice.’ At: https://www.gmc-uk.org/professional-standards/the-professional-standards/good-medical-practice/domain-1-knowledge--skills-and-development.

This is also likely to provide leeway for an emergency – so-called ‘Good Samaritan’ acts in which there is a duty to utilise professional knowledge beyond that of a member of the general public.

Your professional responsibility is to act within your competence and training to ensure both your safety and the well-being of those you serve. If you're ever in doubt, it's always best to be cautious and seek proper guidance.

If you believe that the request to act outside your qualifications could compromise patient care, you have an ethical duty to raise this concern with supervisors or other appropriate channels. Ensuring the right care is provided by qualified professionals is in the best interest of the patient.

● How might these considerations be adjusted for arranging healthcare for non-military beneficiary populations such as children, pregnant mothers and the elderly?

● How might these considerations be adjusted for small medical teams supporting high-risk forces? - e.g. mobile surgical teams in support of Special Forces operations – See: Eibner, Christine. Maintaining Military Medical Skills During Peacetime: Outlining and Assessing a New Approach. 1st ed., RAND Corporation, 2008. JSTOR. At: www.jstor.org/stable/10.7249/mg638osd

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024

Good Medical Practice. Domain 1 Knowledge, Skills and Performance. Apply knowledge and experience to practice. UK General Medical Council. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-1---knowledge-skills-and-performance#paragraph-7 accessed 29 May 2020.

T Woolley, J A Round, M Ingram, Global lessons: developing military trauma care and lessons for civilian practice, BJA: British Journal of Anaesthesia, Volume 119, Issue suppl_1, December 2017, Pages i135–i142, https://doi.org/10.1093/bja/aex382

Dana A, Mohammadimehr M. A Study on Capabilities Required In Military Medicine to Develop Modular Training Courses: A Qualitative Study. J Adv Med Educ Prof. 2017;5(3):134‐147.

Eibner, Christine. Maintaining Military Medical Skills During Peacetime: Outlining and Assessing a New Approach. 1st ed., RAND Corporation, 2008. JSTOR, www.jstor.org/stable/10.7249/mg638osd. Accessed 29 May 2020.