Australian Defence Force (ADF) personnel need to maintain their physical and psychological health in order to undertake their operational duties in defence of Australia and in provision of critical support to communities in need within Australia and overseas.1 In 2014–15, the ADF workforce included 77,274 individuals.2
Many of these individuals perform their roles in austere and hazardous environments (eg submariners, infantry officers undertaking jungle operations and military aviators undertaking low level formation flying at night) where careful selection, training and risk management are imperative. Many will operate from military platforms that contain hazardous materials, which can result in significant exposures. Others will operate under great physiological and psychological stress from cumulative fatigue and continuous threat.
Quality provision of healthcare to the men and women serving in the ADF is a distinct field of practice based on a foundation of the core skills of Australian general practice. General practitioners (GPs) working in an ADF environment largely serve a younger, fitter, healthier patient population than they would treat in civilian populations. They are unlikely to manage the elderly or children and are more likely to manage musculoskeletal injuries and their rehabilitation.3 GPs serving in the ADF are likely to manage service-related mental health issues (eg post-traumatic stress disorder [PTSD], depression, anxiety, stress and grief reactions), which are often exacerbated by separation from key social supports.3,4 Patients may be sent to overseas destinations at short notice, so their GPs are required to have a sound knowledge of travel medicine and tropical medicine. Patients may be deployed on operations in the tropics or arctic areas, deserts or mountain terrain, in hyperbaric and hypobaric environments, and GPs are expected to have familiarity with wilderness medicine, environmental health and occupational hygiene.
ADF GPs may work in difficult environments requiring a broad range of skills, and a flexible and adaptable approach to providing quality care, in order to optimise outcomes for their patients. This may require careful management of resources and effective triaging in environments with limited access to complex investigations and specialist care. This may include mass casualty triaging in war zones and disaster recovery environments including management of aero-medical evacuations.
Preventive health practice is a major part of military general practice. Developing and maintaining an understanding of relevant epidemiology for public health risks of military and civilian significance is important. This includes environmental health risk assessments to minimise the risk of airborne, waterborne and vector-borne diseases. Immunisation; health education and chemoprophylaxis programs; prevention of heat exhaustion; mitigation of acute and chronic musculoskeletal injuries; prevention of physical and mental fatigue; and identification of individuals at risk of acute and chronic mental health disorders are all components of preventive healthcare.
Defence force general practice is unique in the way it works alongside the military command structure and within a military culture. The command and control responsibilities of an ADF general practice medical officer are unlike any in civilian practice. The ADF GP exists within a formation with responsibilities to personnel, to command and to subordinate medical staff. Additional legal, ethical and professional factors impact upon ADF general practice, particularly in deployed circumstances. Familiarity with military culture and the specific responsibilities applicable to this work environment is essential for a GP specialising in military medicine.
The relationship between defence force personnel and their commander is different to that of personnel and supervisors in civilian workplaces. The commander’s responsibilities for his or her personnel typically extend beyond the immediate work environment. They require access to specific health information in order to make decisions around availability of appropriate care, an individual’s capabilities and deployability, and to ensure other personnel are not placed at risk and have the support they require to fulfil their duties.5
Working within the unique sociocultural environment of a defence force unit with its hierarchical structure can be challenging, particularly for civilian GPs. It is essential for GPs to understand their duty of care, including privacy and confidentiality responsibilities within the context of this system and the importance of ensuring that they communicate effectively with the patient’s commander to ensure that occupational health and safety and mission goals are not compromised. Maintaining appropriate doctor–patient boundaries can be challenging when living in close quarters with your patients. Managing the consequences of adverse medical employment classification assessments on an individual’s deployability is another important skill to develop.
Self-care, including accessing mentoring, debriefing and support, is important for all GPs, but is particularly pertinent for those working in often physically and emotionally stressful environments on military deployments.
Once individuals are discharged from military service, GPs in the community play an important role in assisting them to engage with civilian primary healthcare and, if appropriate, undertaking Medicare-funded ADF post-discharge health assessments. GPs in the community can provide support to individuals applying for benefits provided through the Department of Veterans’ Affairs (DVA) and should be aware of the specialist services available to veterans. There were 208,000 holders of a DVA repatriation health card in 2015.6