Textbook of Maritime Medicine

12.4.1   Social Status and Roles

The physician is the center of cruise medicine; on a one-doctor ship he can be considered the most important person aboard as the ship can’t sail without him. The position holds a significant amount of responsibility. Although the master is above all personnel aboard, and the doctor technically reports to the medical center administrator (MCA; on most ships the staff captain or the hotel director), he is responsible for all medical decisions in the MC.

The doctor is usually a ‘Three-Stripe-Officer’ with Senior Officer privileges. On ships with two physicians, the junior doctor may have 2.5 stripes or the senior doctor 3.5 stripes. If the ship has more than one physician, one of them will be expected to always be on call aboard.

As part of his overall responsibilities as a senior officer while aboard the vessel, the doctor may attend and host certain shipboard functions during the course of a cruise.

12.4.2 Qualifications

Following the ACEP guidelines, CLIA members will require these qualifications:

• Current valid medical license (international or domestic).
• Current valid certification in Advanced Cardiac Life Support
• General medicine or general practice experience plus emergency or critical care experience; board certification, similar international certification, or equivalent experience in any of the following areas: emergency medicine, family practice, or internal medicine
• 3 years of recent clinical experience
• Minor surgical skills
• Fluency in English

12.4.3   Responsibilities and Duties

The doctor is medically and legally responsible for the proper and efficient operation of the MC, including but not limited to all actions of both himself and the nurses. It follows that nurses and any other staffing assignments necessary to fulfill these medical services will be handled administratively and professionally by the doctor.

Professional standards are to be maintained for all medical services needed by passengers and crew due to illness or injury.  The doctor is the sole medical person on board to recommend medicines or medical treatment, and this responsibility may not be delegated to a nurse or any other person on board.  When in doubt, he should refer to an approved medical facility ashore.

As a key player in all on board safety and health procedures, the doctor advises the Master and the MCA on matters affecting the general health and well-being of the passengers and crew, and it is his duty to report to the MCA any violations of good health and safety practices he may observe or has knowledge of.  He also provides technical assistance in complying with the ship’s public health standards and any sanitation issues.

The doctor orders all necessary pharmaceutical and medical supplies for the MC, but all requisitions must be countersigned by the MCA.

The doctor is responsible for the safe custody of drugs and must ensure that the drug cabinet for controlled substances (narcotics) is always locked. American rules and regulations regarding narcotics are strict and should be followed on all ships even when they are (temporarily) outside US jurisdiction. Thus, an accurate inventory log of all controlled substances must be kept up to date, and every item that is withdrawn from the drug cabinet must be recorded in the log with the user’s name and number and signed by the nurse on duty and by the doctor. The stock of narcotics must be checked after each cruise or at least once a month, as well as whenever there is a change in medical personnel. These inventories must be initialed or signed by the controlling nurse and the doctor.  The doctor must be prepared to have the log inspected by local authorities in any port, and he is responsible for giving a correct report to customs when required.

12.4.4   Inspections

The doctor must make certain that all diagnostic and life support equipment both in the primary MC and in the secondary MC is inspected regularly to ensure proper working order, that a log of these inspections is maintained, and that it is reviewed and initialed by the controlling nurse and the doctor after each inspection. Noting name and expiration date of the first drug to expire on the outside of each emergency kit, will simplify inspection.

On the MCA’s request, the doctor may also have to participate in health and sanitation inspections of galleys, bars, crew quarters, pantries and provision areas.

On behalf of the Master, the doctor must ensure that all crew members at sign-on have a medical certificate valid beyond the duration of their contract and keep it on file in the MC.

12.4.5   Emergency Training and Drills

The doctor must make certain that he and the nurses are familiar with all medical emergency evacuation procedures, and of all shipboard regulations that affect their department specifically as well as the ship in general, as specified by the Master, the MCA, the safety officer, the security officer etc. The doctor must participate in the ship’s regular drills for the crew with the nurses, during which they follow orders from the bridge. He is further responsible for arranging and participating in medical emergency drills (‘codes’), including patient transport from cabins and public areas with the nurses at least once a month and also whenever there is a change in medical staff.

The doctor is also expected to provide or arrange for training in basic life-saving procedures (first-aid in unconscious, choking, bleeding and burn patients) of sign-on crew, and in techniques for stretcher and wheelchair transport, lifting of injured patients and other safety and health matters whenever this is requested by the MCA.

12.4.6   The Doctor’s Medical Practice aboard

Medical care to passengers and crew is the main task for the medical staff aboard. The doctor is available for consultation during regular office hours and at any time in case of an emergency. In his capacity as an independent medical provider, the passengers may contact the doctor for medical care. His main role for them is to provide temporary emergency care. For the crew, the doctor is the primary care physician and he is responsible for providing and directing all crew medical care aboard the ship at all times.

A crew member not medically fit for duty is to be confined to his or her cabin or to the MC and is usually expected to be seen by the doctor once - or even twice - a day until again fit for work.

The companies expect the doctor to determine when, and if, a crewmember is to be referred to a specialist ashore. For referrals the medical staff members need know and inform the patient in advance what costs the company (or its insurance company) will cover. Consultations and treatment for work-related injuries and illnesses is usually covered, as are most outpatient emergency and even elective procedures.  However, many items are as a rule not covered:

• Basic vision exams are covered but not glasses.
• Basic dental exams, x-rays and extractions are often covered but not cleanings, caps, fillings, gum disease, etc.
• Cosmetic treatment, birth control devices/medication and termination of pregnancy, maternity, remedies to enhance sexual function or palliative care are rarely covered.

Logs

The doctor should maintain a daily medical log, separate for passengers and crew, where each consultation is listed chronologically with cabin number, name, diagnosis, treatment, referrals and, for crew, also crew number, position, work status, etc.

Furthermore, the MC must retain accurate logs of illnesses and injuries for each passenger and crew seeking medical attention. All visits must be recorded regardless of the nature of the problem, and all written communications must be in the official language of the company, which is mostly English.

Each company has its own standards for patient logs, from handwritten notes to advanced, lockable software systems. Regardless of systems used, a clear and complete medical log is an important medical record of patient care and is also a document which might be used as evidence in a court case.  As such, it is essential to record information in a prudent and professional style.

In addition to the regular patient log, injuries trigger separate company-specific accident reports, and Centers for Disease Control and Prevention require special logs and reports for suspected gastroenteritis, Legionnaires’ disease and other infectious diseases.

Fees

Passengers have to pay fixed fees for the various medical services aboard most ships, determined by each company, and if referred to specialists ashore, they must also cover the specialists’ fees. However, for goodwill reasons, treatment for injuries caused by accidents on board or during company-promoted shore excursions is usually free, as are examinations to rule out - and treatment for – gastroenteritis.

Legal Aspects

On most ships the doctor is still considered an independent contractor, not a company employee. Companies argue that they are not in a position to control or even supervise the doctor’s medical practice aboard.

However, there are many arguments to support the opinion that the physician is in fact an employee: The doctor is under the command of the ship’s Master and reports administratively to the MCA. There are company rules to be followed regarding certain technical aspects of the medical practice aboard, and most companies have a Medical and/or Risk Management Department that in many ways will interfere with the doctor’s practice aboard. The Doctor usually wears the company’s uniform. Most ship’s doctors are now on a regular salary that covers all aspects of his work aboard, including passenger and crew consultations and treatments. Furthermore, most companies supply (limited) coverage against malpractice suits through the ship’s insurance.

Any accident, in fact any medical staff/ patient encounter, may result in litigation. For the company it is important to ensure the full cooperation of the doctor and the nurses and vice versa. The primary litigation target is usually the company, but a victim often ‘throws a wide net’ initially and also includes the ship’s management and members of the medical staff in the law suit, claiming missed injuries, wrong diagnosis or treatment, incompetence, negligence, abandonment etc. For the company it will then be important to distance itself from the medical staff members by pointing out that the doctor’s and the nurses’ credentials were screened by independent experts, and that the ship did nothing to prevent the doctor from doing his job properly. In case of claimed medical malpractice by the doctor without any involvement by the ship or the company, litigation might be brought against the doctor only, but then usually in the county in which his license was issued.

The doctor should always take threats of a law suit very serious, but not personal. In any case of litigation he should cooperate fully with the company’s risk management and defense counsel and at all times keep them well informed.

If the doctor recommends that an ill or injured passenger should be hospitalized ashore and the patient refuses to leave the ship, or refuses to stay at the hospital ashore and returns to the ship, the doctor should have the patient sign a ‘Letter of Indemnity’ indicating that the passenger is continuing the cruise against the advice of the ship's doctor. Such a signature does not mean that the patient is no longer the doctor’s concern. On the contrary, the medical staff will still be expected to do their very best; the patient has merely been warned in advance that their best may not be good enough.

If the passenger refuses to sign any forms, the doctor should document that and try to obtain witness reports to that effect.

Detailed written documentation of information obtained, findings, considerations/ deliberations, treatments during the consultations as well as documentation of all follow-up will be key elements of a successful litigation defense.

These days most companies get sued more often by crew than by passengers.

It should be noted that there is hardly any insurance available that covers gross negligence by a physician at sea – or on land.

For a detailed overview of the doctor’s administrative and professional responsibilities and duties, please see: Appendix 2 - A modified Description for Ship’s Doctors