All of the scenarios in the garrison healthcare suit should be considered from the perspective of a healthcare professional working in a military garrison healthcare centre with responsibility for the clinical care of patients and management of the healthcare centre. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ . You should also consider your national professional ethical codes and relevant military law or guidance

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: Your partner complains that you are working too hard and this affects your relationship with them and your children. You requested support from your superiors. They say that no one can help and that your duties are the same as everyone else. What do you do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding looking after yourself and managing workload and stress. It includes the duty of employers to look after their people. As well as the workload issue, you might consider the implications of gender, spousal employment, and childcare responsibilities.  

Step 2 – ANALYSE

Patient: you need to consider the potential impact of workload and family stress on your relationships with patients and your professional judgement. You also have to consider whether you might be a ‘patient’ in the context of this scenario and whether to seek healthcare support. You should ensure that you are appropriately registered with a primary care physician and that you are able to seek help confidentially - this means probably not being registered in their own practice.

Clinical: you need to consider the potential impact of workload and family stress on your relationships with colleagues and staff within your workplace and on your performance.

Legal: Your ‘employer’ also has to take the appropriate mitigations to protect the health of their employees – system of work, protective equipment, training and education – from the risk work-related stress and workload.

Societal/Military: you have a duty to your ‘employer’ to follow legal orders and to perform your duties to meet reasonable expectations. The nature of the military environment and the hierarchical structure may put undue pressure on subordinates not to raise concerns in a timely manner.  You have a duty to your patients to maintain your own health in order to perform your duties to the required standard.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

The WMA Code states: 28. In order to provide care of the highest standards, physicians must attend to their own health, well-being, and abilities. This includes seeking appropriate care to ensure that they are able to practise safely. AND 32. The physician should report to the appropriate authorities conditions or circumstances which impede the physician or other health professionals from providing care of the highest standards or from upholding the principles of this Code. This includes any form of abuse or violence against physicians and other health personnel, inappropriate working conditions, or other circumstances that produce excessive and sustained levels of stress.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

You might share your issues with a trusted peer or colleague to get an external perspective. You need to reinforce your request for support. This might involve a face-to-face meeting or a written letter. You should also assess whether your workload is reasonable relative to other colleagues in an equivalent situation. You might also consider self-referral for mental health support. Beyond work, you might consider whether there are other external factors affecting your relationship with your partner – clashes over sharing of work and domestic duties – that influence their perceptions of your commitment to your work.  You may wish to seek advice from your professional body.

Contributors – Brigadier (Rtd) Charles Beardmore MBBS MRCGP MFOM MA MSc MBA LLM. Charlie is a qualified General Practitioner with 32 years of military service that culminated in the role of Head of Defence Primary Healthcare in the UK. He is studying for a PhD on the topics of military healthcare ethics. Brigadier Phil Carter MBChB MRCGP MPH MA. Phil is a qualified General Practitioner with 28 years of military service, He recently served as Commander of Defence Primary Healthcare in the UK and Chief Medical of a multinational operational headquarters in the Middle East.