_06_IMH_2015_3_Ottomann

REVIEW ARTICLE

Ship’s doctors qualifications required for cruise ships: Recruiter’s comments on the German — Norwegian debate

Christian Ottomann

Schiffsarztbörse / Medical-Shipmanagement, Lübeck, Germany

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Priv.-Doz. Dr. med. Christian Ottomann, Schiffsarztbörse / Medical-Shipmanagement, Hartengrube 52, 23552 Lübeck, Germany, e-mail: info@medical-shipmanagement.com

ABSTRACT

This contribution is intended to fertilise the current discussion of ship’s doctors qualifications required for cruise ships. Therefore 10 points are added to the debate containing different considerations focussing on the recommendations of the German Society of Maritime Medicine, the American College of Emergency Physicians (ACEP’s) Health Care Guidelines for Cruise Ship Medical Facilities and the different skills a ship’s doctor should have from the perspective of the recruiter.

(Int Marit Health 2015; 66, 3: 160–163)

Key words: ship’s doctors qualification, cruise ship, recruiter, CLIA, maritime training, soft skills

RESTRICTED AVAILABILITY OF DATA AND ONGOING DEBATE

Only a few epidemiological studies have been published on the incidence and prevalence of certain diseases and traumas amongst multinational crew members and passenger patient collectives, the makeup of which depends on which cruise line they are travelling under, and which market segments are being catered for [1–7]. The designated ship’s doctor, however, needs to be aware of the variety of medical risk profiles that await him on the cruise ship depending on the crew or passengers which the ship is carrying. Depending on the cruise provider, route and the additional leisure programme on offer, maritime incidents such as diving accidents, hypothermia or drownings can occur as well as infections with rare tropical diseases, albeit mainly amongst the crew in the latter case [8, 9]. All this has led to a discussion within the International Maritime Health Association (IMHA) as to how a ship’s doctor should be qualified for the duty on-board cruise ships, and to what extent further maritime medical training is necessary for this. Furthermore, the adoption of healthcare guidelines for cruise ship facilities is being considered by the Cruise Line International Association (CLIA), as is the question whether specific training content for ship’s doctors regarding American College of Emergency Physicians (ACEP’s) recommendations etc. should also be incorporated into international regulations [10]. The ACEP guidelines are already promoted by CLIA, which makes them binding for the CLIA members, more than 90% of the major cruise lines are CLIA members. The ten points listed here should provide a further contribution to this topical, important and lively debate.

PROVIDERS OF MARITIME EDUCATION AND TRAINING IN GERMANY

Medical Shipmanagement® (Schiffsarztbörse®) is an international German-based medical recruitment agency which was founded in 2010, and which specialises in the placement of ship’s doctors for cruise ships. Due to the lack of qualified ship’s doctors it also organises a 10-day on-board “Compact Course Maritime Medicine” on cruise ships for those intending to become ship’s doctors [11]. In Germany there are also other providers of maritime medical training, whereby one supplier favours training based on a modular shoreside system (basic, advanced and professional course) and the other favours a web-based online training system [12].

THE GERMAN-NORWEGIAN DEBATE

One publication providing guidance regarding the qualifications required of ship’s doctors on cruise ships was published by Dahl in 2009 [10]. Dahl stated that there are no international rules governing ship’s doctor training for cruise ships. He also pointed out that training content is not specified, and referred to the continuously updated recommendations of the ACEP, which at the start of the 90s are already being incorporated into the Health Care Guidelines for Cruise Ship Medical Facilities. The Guidelines of the ACEP have been included in the recommendations of the CLIA. Recently in 2015, Seidenstücker and Neidhardt published results from the working group “Ship’s doctor training” of the German Society of Maritime Medicine (DGMM), which lay the basis for a predefined curriculum for maritime medical training. The working group consisted of 19 experts with various backgrounds in maritime medicine. A literature review was carried out on cruise ship epidemiology which included an assessment of the tasks and environmental factors that influence medical care on-board cruise ships [13]. Immediately after that Dahl and Stannard [14] claimed that many of the subjects listed in the DGMM that apply to all crew members can be dealt with briefly in a pre-sea course because they will be covered in detail during long mandatory lectures during all crewmembers first 2 weeks aboard. According to Dahl and Stannard [14], all that a ship’s doctor needs to know about before signing on are matters such as taxes and insurance, vaccinations and prophylaxis, travel and tropical medicine, radiation protection and the handling of corpses etc., all of which can be covered in short and to-the-point lectures, with each lasting only a few minutes [14]. In another short discussion paper in the IMHA Newsletter 04/2015, Dahl [15] forwards his thesis that although a broad medical knowledge and skills are important at sea, there are other central qualifications that are not so easy to formalise, namely diplomacy and skills in various languages. In the IMHA Newsletter 05/2015, Seidenstücker answered that being a ship’s doctor is a serious task very different to medicine ashore, that it deserves special education and training, and that being a ship’s doctor is anything but leaning on a railing in front of a Caribbean sunset [16]. This contribution is intended to fertilise the somewhat theory-laden discussion from the perspective of the recruiter. For this reason we would like to add the following comments to the discussion.

TEN POINTS TO ADD

  • As Seidenstücker correctly concluded, the body of epidemiological data which awaits the ship’s doctor on-board cruise ships for medical challenges is extremely scant [1]. As such it would be useful for cruise lines to carry out internal training for their ship’s doctors that is geared towards the risk profiles of the passenger collectives they cater for. If a cruise line outsources the training, the cruise line should inform the training organisers of the specific risk profiles of their target audience and passenger clientele with the help of epidemiological data, so that training can then be tailored appropriately.
  • If a cruise line offers no company internal training, an inexperienced ship’s doctor will be groping around in the dark when it comes to making diagnoses and treating emergencies on board. This is because the cruise industry does not publish epidemiological data because of its desire to protect the image of its “Sunshine Industry”. A broad medical knowledge and long experience is easy to demand of young physicians, but is unrealistic given the sub-specialisation into the various medical specialties which physicians are increasingly undertaking.
  • As a doctor, you can learn a company’s internal maritime training only if you’re already hired as a ship’s doctor, a classic catch 22 scenarios. Cruise lines prefer older medical colleagues who are already experienced with working on board, while younger colleagues who may even yearn to sail as a ship’s doctor receive no company internal maritime training because they are not hired.
  • A doctor may also be criminally liable if he or she is not qualified enough to treat a particular medical situation properly. Any unqualified treatment attempted by the ship’s doctor can then be interpreted as a criminal offence in German law and taken before a court. The rules of national and international law must always be considered when carrying out one’s profession as a ship’s doctor. Here a further distinction needs to be made between criminal law and civil law, because in contracts the insurance conditions use civil law as a basis [17]. The risk to the ship’s doctor under liability insurance law, however, is mainly borne under civil law and does not impact on individuals working in public service. Where damages are sued, any lawyer worth his salt will sue the cruise line, the recruiter and the ship’s doctor simultaneously, since in this way the lawyer can ensure that all possible defendants are brought into the litigation process [18]. For this reason, from an insurance law perspective the ship’s doctor should ensure that he or she has a maritime qualification and that he or she is trained and certified as a ship’s doctor so that the personal liability risk can be minimised. In order to limit the liability for all the parties (cruise line, recruiter, ship’s doctor), only fully qualified medical personnel should therefore be recruited [19].
  • The DGMM through its recommendation of a curriculum has made a valuable contribution to the quality of ship’s doctor training, which should also be reflected in the training content from maritime medical training providers and which should also be incorporated in internationally binding guidelines for ship’s doctor training. How large the curriculum should be, remains an open question. Sadly this reflects the status quo, namely that not all cruise lines check the qualifications of the ship’s doctor properly [20].
  • A focussing on the ACEP guidelines with its numerous sheltered training courses (ACLS/PALS/ATLS) is worthy of some discussion, since modifications and innovations of the ACEP guidelines are incorporated into the medical recommendations of the CLIA with almost no input from the IMHA. It is true that the likelihood of a reanimation requiring medical emergency on-board increases as the number of cruise ship passengers and the sizes of the cruise vessels increase. However, whether ATLS certification is still in fact necessary for ship’s doctors does not seem to be supported by any epidemiological data. Here one might also ask the extent to which recommendations for ACLS/PALS/ATLS depend on certain lobby interests and whether these courses were ever evaluated at sea [21–23].
  • Because the guidelines of the ACEP were being focussed upon more and more by the cruise lines, long-serving and highly competent ship’s doctors were gradually being filtered out simply because they did not meet certain bureaucratic requirements (e.g. the ACLS certification had expired or an arbitrary age limit set by the cruise line had been surpassed). The broad medical experience of the ship’s doctor mentioned by Dahl is certainly more important than completion of certain courses prescribed by the ACEP [14, 15]. The focussing on specific guidelines or curriculum content can only allow cruise lines to make a purely formal assessment of the qualifications of the ship’s doctor. The selection for a particular vessel, however, should only be carried out by individuals with a medical background. For this reason it is proposed that attention be paid to providing a certain leeway in formulating the required training content.
  • From the experience of the 10-day “compact course maritime medicine”, only about 10% of the course participants actually become ship’s doctors. Too many physicians underestimate the responsibility for several thousand passengers and hundreds of crew members, and only recognise from on-board courses that relevant medical decisions have a different gravity than they do on land. A self-assessment as to whether an individual is suitable to work as a ship’s doctor can also only be acquired with difficulty within a land-based or online-based maritime training concept.
  • From the perspective of the recruiter, the soft skills of the ship’s doctor postulated by Dahl (diplomacy, empathy, language skills) should not be neglected, because the cruise industry is very focussed on customer satisfaction and the results of its evaluation. Passenger complaints about the ship’s doctor are taken very seriously. However, since passengers may sometimes simulate diseases and traumas (especially at the end of a cruise) in order to make an insurance claim for reducing the cost of the cruise, or to get a discount on the next booking due to an alleged reduction in quality due to illness, a high level of diplomatic skill is required on the part of the ship’s doctor. Ship’s doctors should at least be bilingual, or better still have multilingual skills. However, such skills, along with an individual’s capacity to work in a team, are very difficult to evaluate during the recruitment process. Experience tells us that individuals can sometimes even reveal themselves to be diametrically opposed to the impression they gave during the recruitment process. As such, a maritime compact course in which the potential ship’s doctors can be accustomed to on-board conditions for ten days would be useful. An assessment of who has the necessary soft skills cannot be made from a 3-h lecture.
  • Cruise ship owners and recruiters want ship’s doctors who have 1) a sound medical education, 2) completed a maritime training or education, 3) practised emergency medical skills at their disposal, 4) X-ray certifications, 5) excellent IT skills, 6) billing and documentation skills, and who are, 7) fit for sea service, 8) team players, 9) at least bilingual, and 10) prepared to spend 8–12 weeks on board. Since the number of physicians who have these skills and time availability is very limited, the question of proper pay cannot be left aside in this debate. Too often the rule is neglected, that no cruise ship is permitted to go to sea without a ship’s doctor on board.

CONCLUSIONS

A worthy point of criticism is the contradiction that cruise lines on the one hand retain their epidemiological data, so as not to endanger the image of the Sunshine industry, and on the other they still demand optimally qualified ship’s doctors. The ship’s doctor, in order to minimise the liability risk for all parties (cruise line, recruiter, ship’s doctor), must have completed a maritime medical training programme and be certified as such as a ship’s doctor. The DGMM through its recommendation of a curriculum has made a valuable contribution to the quality of the ship’s doctor training, which should also be reflected in the training content from maritime training providers and should also be incorporated in internationally binding guidelines for ship’s doctor training. Whether the curriculum developed within the DGMM, as promoted by Dahl and Stannard, is too costly, is the subject of the current lively discussion. From the perspective of the recruiter, the soft skills of the ship’s doctor postulated by Dahl should not be neglected, because the cruise industry is very focused on customer satisfaction and the results of its evaluation. As such a recruiter must be focussed on a sound medical education, including a maritime medical training for becoming a ship’s doctor, as well as on soft skills, whereby a great deal of experience is required during the recruitment process. These ten points should provide an additional contribution to the current valuable discussion about the requirements a ship’s doctor must have, about the extent of training required for a ship’s doctor, and the direction in which cruise medicine shall evolve in the future against the backdrop of the ongoing boom within the international cruise industry.

CONFLICT OF INTEREST

The autor has worked for different cruise lines as recruiter and is the founder and organiser of the International Course in Cruise Ship Medicine mentioned in the text.

REFERENCES

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